Orthopedic Board Review MCQs: Foot, Knee & Deformity

About This Board Review Set

This is Part 197 of the comprehensive OITE and AAOS Orthopedic Surgery Board Review series authored by Dr. Mohammed Hutaif, Consultant Orthopedic & Spine Surgeon.

This set has been strictly audited and contains 100 100% verified, high-yield multiple-choice questions (MCQs) modelled on the exact format of the Orthopaedic In-Training Examination (OITE) and the American Academy of Orthopaedic Surgeons (AAOS) board examinations.

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Two distinct learning modes are available:

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Pro Tip: Use keyboard shortcuts A–E to select options, F to flag a question for review, and Enter to jump to the next unanswered question.

Topics Covered in Part 197

This module focuses heavily on: Ankle, Deformity, Foot, Knee.

Sample Questions from This Set

Sample Question 1: A 48-year-old man has recurrent right knee pain. Figure 52a shows the sagittal proton density T2-weighted MRI scan, and Figure 52b shows the sagittal T2-weighted MRI scan at the same level. The arrow is pointing to a...

Sample Question 2: Figure 18a shows the clinical photograph of a 31-year-old man who has a slowly growing nodule on his right middle finger. It is minimally tender, and there is no erythema on examination. A biopsy specimen is shown in Figure 18b. What is the...

Sample Question 3: Figures 155a and 155b are the plain radiographs of a 17-year-old boy who recently noted painless swelling in his distal thigh. Examination reveals a firm, fixed, deep distal thigh mass. There is no associated tenderness. What is the best ne...

Sample Question 4: During percutaneous iliosacral screw placement for an unstable pelvic ring injury, use of the lateral sacral fluoroscopic image is critical to help avoid iatrogenic injury to what structure?...

Sample Question 5: A 17-year-old high school football player injures his right ankle during a game. Examination reveals swelling and a closed ankle deformity, with normal foot circulation and sensation. Radiographs are shown in Figures 10a and 10b. In additio...

Why Active MCQ Practice Works

Evidence consistently demonstrates that active recall through spaced MCQ practice yields substantially greater long-term retention than passive reading alone (Roediger & Karpicke, 2006). All questions in this specific module have been algorithmically verified for clinical integrity and complete explanations.

Comprehensive 100-Question Exam

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Question 1

A 48-year-old man has recurrent right knee pain. Figure 52a shows the sagittal proton density T2-weighted MRI scan, and Figure 52b shows the sagittal T2-weighted MRI scan at the same level. The arrow is pointing to a

Explanation

DISCUSSION: Meniscal tears have many configurations and locations. The normal medial meniscus has a bow-tie configuration on the two most medial consecutive sagittal views. Toward the center of the joint the anterior and posterior horns have a triangular shape. These images show an abnormal intra-articular low-signal structure located anterior to the intact posterior cruciate ligament. This most likely represents a torn and displaced posterior horn of the medial meniscus, sometimes called “double PCL sign.” A popliteal cyst and ligaments of Wrisberg and Humphry are not visible on these figures.
REFERENCES: Helms CA: MR image of the knee, in Fundamentals of Skeletal Radiology, ed 2. Philadelphia, PA, WB Saunders, 1995, pp 172-191.
Mink JH, Deutsch AL: The knee, in MRI of the Musculoskeletal System, ed 1. New York, NY, Raven Press, 1990, pp 251-387.

Question 2

Figure 18a shows the clinical photograph of a 31-year-old man who has a slowly growing nodule on his right middle finger. It is minimally tender, and there is no erythema on examination. A biopsy specimen is shown in Figure 18b. What is the most likely diagnosis?

Explanation

DISCUSSION: Epithelioid sarcoma is the most common soft-tissue sarcoma in the hand and most commonly occurs in young adults. The tumors can be superficial and may become ulcerated. Deeper lesions are often attached to tendons, tendon sheaths, or fascial structures. These are usually minimally symptomatic. The biopsy specimen reveals the typical appearance of a nodular pattern with central necrosis. They can mimic a necrotizing granulomatous process. Usually there are chronic inflammatory cells along the margin of the tumor nodules. This biopsy specimen does not have the clear cells necessary for a clear cell carcinoma or sarcoma. Nora’s tumor is a bizarre parosteal osteochondromatous proliferation (BPOP) first described in 1983 by the pathologist, Nora. The lesion is defined as a reactive heterotopic ossification and is mostly found in the hands or feet of adults in the third decade of life.
REFERENCES: Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St Louis, MO, Mosby, 1995, p 1074.
Halling AC, Wollan PC, Pritchard DJ, et al: Epithelioid sarcoma: A clinicopathologic review of 55 cases. Mayo Clin Proc 1996;71:636-642.

Question 3

Figures 155a and 155b are the plain radiographs of a 17-year-old boy who recently noted painless swelling in his distal thigh. Examination reveals a firm, fixed, deep distal thigh mass. There is no associated tenderness. What is the best next treatment step?

Explanation

Question 4

During percutaneous iliosacral screw placement for an unstable pelvic ring injury, use of the lateral sacral fluoroscopic image is critical to help avoid iatrogenic injury to what structure?

Explanation

DISCUSSION: Unstable anterior and posterior pelvic ring injuries are amenable to percutaneous treatment if reduction is able to be obtained in a closed manner and appropriate radiographic visualization is able to be achieved. In the 1996 reference by Routt et al, proper SI screw placement is described. Pelvic inlet, outlet, and lateral sacral images must be obtained to safely place a percutaneous iliosacral screw. The iliac cortical density seen adjacent to the SI joint is the anterior edge of the insertion safe zone, and is only able to be seen on the lateral image. Failure to place the screw behind this radiographic line would lead to an "in-out-in" screw (in the ilium, and then exiting anterior to the sacral ala, only to re-enter in the sacral body), which would cause direct injury to the L5 nerve root.
In the 2000 reference by Routt et al, they state "a thorough knowledge of pelvic osseous anatomy, injury patterns, deformities, and their fluoroscopic correlations are mandatory for percutaneous pelvic fixation to be effective."
Illustration A shows a representative lateral sacral radiograph, with the major anatomic landmarks labeled. Safe SI screw insertion in the S1 body should be underneath the sacral ala line to minimize risk of a "in-out-in" screw that would come out in the area of the ala and injure the L5 nerve root that sits directly on top of this structure. Dysmorphic pelvic rings will often have a more vertical sacral line, or one that starts more inferiorly.

Question 5

A 17-year-old high school football player injures his right ankle during a game. Examination reveals swelling and a closed ankle deformity, with normal foot circulation and sensation. Radiographs are shown in Figures 10a and 10b. In addition to closed reduction, management should include

Explanation

DISCUSSION: The examination and radiographs reveal a closed fracture-dislocation of the ankle with tibiofibular diastasis. Immediate fixation of the medial malleolus and plating of the fibula are indicated. If residual tibiofibular diastasis occurs with lateral translation of the fibula after plating, a syndesmotic screw is placed to stabilize the syndesmosis. Ankle fracture-dislocations associated with a proximal fibular fracture (Maisonneuve fracture) require syndesmotic fixation, but the fibula is not plated. Unstable ankle fractures require surgical treatment. If swelling is severe (fracture blisters, loss of skin wrinkling), a compressive splint is applied and surgery is delayed for 5 to 7 days.
REFERENCES: Browner BD, Jupiter JB, Levine AM, Trafton PG: Skeletal Trauma. Philadelphia, PA, WB Saunders, 1992, pp 1887-1957.
Stiehl JB: Ankle fractures with diastasis. Instr Course Lect 1990;39:95-103.

Question 6

A 24-year-old man is ejected from his motorcycle and sustains a significant hip injury. The fracture shown in Figures 64a through 64e is best described as what type of fracture?

Explanation

DISCUSSION: The radiographs and CT scans reveal an anterior column acetabular fracture. The fracture has quadrilateral plate extension but does not exit out the posterior column. The CT scans confirm an intact posterior column and no wall fracture. A transverse fracture is best seen on the CT scan and runs in the sagittal plane, not the coronal plane.
REFERENCES: Letournel E, Judet R: Fractures of the Acetabulum, ed 2. New York, NY, Springer-Verlag, 1993, pp 115-140.
Beaule PE, Dorey FJ, Matta JM: Letournel classification of acetabular fractures: Assessment of interobserver and intraobserver reliability. J Bone Joint Surg Am 2003;85:1704-1709.

Question 7

Which of the following provides the most stable fixation for comminuted fractures of the posterior acetabular wall?

Explanation

According to the first sited article (Goulet et al, JBJS, 1994) “…comminuted fractures so close to posterior rim (i.e. comminuted fractures)… are amendable only to stabilization with a plate…a buttress plate enhances stability of fixation for comminuted fxs of the poster wall of the acetabulum.” “Fixation requires rigid fixation to prevent loss of fixation resulting in incongruity and instability.”
According to Rockwood & Green and Browner & Jupiter the key to fixing these fractures is to re-establish a congruent articular surface. The other four distracters (i.e. cable, methylmethacrylate, multiple lag screws, and multiple K-wires) may achieve initial stability, but reduction will not be maintained. In addition, further studies show a higher incidence of mortality and complications with the use of lag screws and K-wires alone (Browner & Jupiter, Skeletal trauma, 1998)

Question 8

A 72-year-old man who underwent total shoulder arthroplasty 2 years ago slipped on ice and fell on his shoulder 3 weeks ago. Immediately after falling he was unable to elevate his arm. Motor examination reveals deltoid 5-/5, subscapularis 5-/5, external rotation 4-/5, and supraspinatus 2/5. Radiographs are shown in Figures 8a and 8b. What is the most likely diagnosis?

Explanation

DISCUSSION: The patient has a traumatic rotator cuff tear. The history of the fall, the weakness on examination, and normal radiographic findings make a traumatic rotator cuff tear the most likely diagnosis. An MRI scan can be obtained to further evaluate the integrity of the rotator cuff. The axillary radiograph shows a reduced, nondislocated total shoulder arthroplasty. His radiographs show a well-seated humeral stem and no signs of loosening. The glenoid is a cemented all-polyethylene component with no evidence of radiolucent lines surrounding the cemented pegs. The polyethylene glenoid component is radiolucent; however, the space between the metallic humeral head and the glenoid bone is the thickness of the polyethylene glenoid component. If the humeral head were directly against the glenoid bone, then catastrophic fracture of the glenoid would be the working diagnosis.
REFERENCES: Hattrup SJ, Cofield RH, Cha SS: Rotator cuff repair after shoulder replacement. J Shoulder Elbow Surg 2006;15:78-83.
Sperling JW, Potter HG, Craig EV, et al: Magnetic resonance imaging of painful shoulder arthroplasty. J Shoulder Elbow Surg 2002;11:315-321.

Question 9

Thoracic disk herniations most typically occur at what level of the thoracic spine? Review Topic

Explanation

Most thoracic disk herniations occur in the lower (caudal) third of the thoracic spine. This predilection may be related to the unique anatomic and biomechanical environment of that region. The 11th and 12th ribs do not join the rib cage anteriorly and do not form a true articulation with the transverse processes posteriorly. Furthermore, flexion and torsional forces tend to concentrate between T10 and L1.

Question 10

A 45-year-old right-hand dominant woman falls onto an outstretched left hand. Imaging shows a complex elbow dislocation. The postreduction CT scan demonstrates a reduced joint, comminuted radial head fracture, and type I coronoid fracture. Surgical intervention is recommended to address the involved structures. Which component of the intervention adds the most rotational stability?

Explanation

A 68-year-old right-hand dominant woman has experienced progressive right elbow pain and loss of motion for several years. She has failed nonsurgical treatment and elects to undergo a total elbow arthroplasty (TEA). In comparison to a linked prosthesis, an unlinked prosthesis has which reported distinction with extended follow-up?

A. Improved longevity in comparison to the linked prosthesis

B. A significantly larger flexion-extension arc

C. A higher incidence of postsurgical instability

D. Lower frequency of ulnar nerve dysfunction

TEA is a popular option for treatment of end-stage elbow arthritis for elderly, lower-demand patients with rheumatoid arthritis. Good success rates have been published by several authors. The clear benefit of the current nonconstrained prosthesis has yet to be proven. Plaschke and associates investigated the Danish National Patient Registry to compare the longevity of the 2 types of implants. These authors found similar survival rates associated with both linked and unlinked implants at 10 years (88% and 77%, respectively). However, studies have documented an approximate 20% incidence of postsurgical instability with nonconstrained implants.

Question 11

A 70-year-old man seen in the emergency department has had left shoulder pain and a fever of 101.5 degrees F (38.6 degrees C) for the past 3 days. He denies any history of trauma. Examination reveals tenderness anterosuperiorly and at the posterior glenohumeral joint line. He has very limited range of motion (passive and active). Laboratory studies show a WBC count of 12,000/mm 3 and an erythrocyte sedimentation rate of 48 mm/h. Initial management should consist of

Explanation

DISCUSSION: It appears that the patient has septic arthritis of the glenohumeral joint; therefore, initial management should consist of aspiration of the glenohumeral joint and subacromial space separately, followed by Gram stain and culture of the fluid. Based on the findings, broad-spectrum IV antibiotics should be started. If the diagnosis of septic arthritis is confirmed, then arthroscopic or open surgical drainage usually is indicated.
REFERENCES: Sawyer JR, Esterhai JL Jr: Shoulder infections, in Warner JJ, Iannotti JP, Gerber C (eds): Complex and Revision Problems in Shoulder Surgery. Philadelphia, PA, Lippincott-Raven, 1997.
Leslie BM, Harris JM, Driscoll D: Septic arthritis of the shoulder in adults. J Bone Joint Surg Am 1989;71:1516-1522.

Question 12

Bleeding is encountered while developing the internervous plane between the tensor fascia lata and the sartorius during the anterior approach to the hip. The most likely cause is injury to what artery?

Explanation

DISCUSSION: The ascending branch of the lateral femoral circumflex artery crosses the gap between the tensor fascia lata and the sartorious and must be identified and ligated or coagulated. The other vessels are out of the field of dissection.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 312.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 304.

Question 13

You are counseling a 55-year-old woman for a right carpal tunnel release. What can you tell her about the treatment benefit (grip strength and paresthesia relief) 1 year after surgery compared with continued splinting, NSAID use, physical therapy, and a single steroid injection?

Explanation

EXPLANATION:
Gerritsen and associates, Hui and associates, and Jarvik and associates compared the effectiveness of surgical versus nonsurgical treatment for the relief of carpal tunnel symptoms. All three studies showed that surgery was superior for the relief of paresthesias and the improvement of grip strength. According to the American Academy of Orthopaedic Surgeons Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome, strong evidence supports the assertion that surgical treatment of carpal tunnel syndrome should have a greater treatment benefit at 6 and 12 months than splinting, NSAIDs, physical therapy, and a single steroid injection. The other choices, including no change in grip strength and
paresthesias, decrease in grip strength and increase in paresthesias, and increase in grip strength and paresthesias, are not supported by the evidence.

Question 14

A 39-year-old man has had a foot mass for the past several months. MRI scans are shown in Figures 78a through 78c. A core biopsy specimen reveals synovial sarcoma, and a staging chest CT scan is normal. Which of the following treatments offers the best local tumor control and expedites the patient’s return to normal function?

Explanation

DISCUSSION: Certain histologic subtypes of soft-tissue sarcoma have been noted to arise preferentially in the hand and the foot, such as epithelioid sarcoma, clear cell sarcoma, and synovial sarcoma. Synovial sarcoma is the most common foot sarcoma. Frequently there is a delay in diagnosis because the lesions are rare. The lesions tend to occur in younger adults, typically between the ages of 15 and 40 years. Patients with hand and foot sarcomas have been described as having improved overall survival, but this is likely a result of the smaller size of tumors arising in these locations. In this patient, the tumor has grown to a substantial size and involves many of the bones of the midfoot. Limb salvage may be a possibility when incorporated into a multidisciplinary treatment program, but this will entail months of adjuvant treatment and significant morbidity. Amputation and early prosthetic fitting still have a role in management of some soft-tissue sarcomas, most frequently in the foot.
REFERENCES: Ferguson PC: Surgical considerations for management of distal extremity soft tissue sarcomas. Curr Opin Oncol 2005;17:366-369.
Scully SP, Temple HT, Harrelson JM: Synovial sarcoma of the foot and ankle. Clin Orthop Relat Res 1999;364:220-226.

Question 15

Immobilization with a sling

Explanation

Upon review of the radiograph in fig. 63 it has the appearance of a classic Unicameral Bone Cyst of the proximal humerus of a skeletally immature individual. Also noted is a nondisplaced fracture of proximal humerus through the cyst. The article above gives accepted treatment protocols for unicameral bone cysts:
Radiographically Active Cyst (age 4 to 8 years old with pathologic fracture)
Align and immobilize
Observe for spontaneous healing
Reassess after 2 to 4 months and if recurrent, follow procedure for pathological fracture of radiographically active cysts described in the article above.

Question 16

A 21-year-old man who underwent repair of a distal biceps tendon rupture using a two-incision approach 4 months ago now reports difficulty gaining rotation of his forearm. Figures 49a and 49b show the AP and lateral radiographs. What is the most likely cause of his problem?

Explanation

DISCUSSION: The radiographs show early ectopic bone formation originating between the ulna and the radius. The development of ectopic bone in this area following a two-incision approach for anatomic repair of the distal biceps tendon is thought to be related to exposure of the periosteum of the lateral ulna during surgery. This can be avoided by the use of a muscle-splitting incision between the extensor carpi ulnaris and common extensor muscles. Full pronation of the forearm allows for the necessary exposure of the radial tuberosity during the procedure and for fixation of the tendon at its maximal length.
REFERENCES: Morrey BF: Tendon injuries about the elbow, in Morrey BF (ed): The Elbow and Its Disorders, ed. 2. Philadelphia, PA, WB Saunders, 1993, pp 492-503.
Failla JM, Amadio PC, Morrey BF, Beckenbaugh RD: Proximal radioulnar synostosis after repair of distal biceps brachii rupture by the two-incision technique: Report of four cases. Clin Orthop 1990;253:133-136.

Question 17

The iliopectineal fascia runs between which of the following structures?

Explanation

DISCUSSION: The sheath of the psoas muscle or the iliopectineal fascia separates the more lateral iliopsoas muscle and the femoral nerve from the more medially located iliac vessels. This fascia has to be taken down to enter the true pelvis.
REFERENCES: Masquelet AC, McCullough CJ, Tubiana R: An Atlas of Surgical Exposures of the Lower Extremity. Philadelphia, PA, JB Lippincott, 1993.
Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.
Matta J: Surgical treatment of acetabular fractures, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, vol 1, pp 1109-1149.

Question 18

A 38-year-old woman has a lesion on her left foot that has increased in size over the past 6 months. The clinical photograph is shown in Figure 17a, and a photomicrograph of the biopsy specimen is shown in Figure 17b. What is the most likely diagnosis?

Explanation

DISCUSSION: Melanoma comprises 25% of lower extremity lesions and is the most common malignant tumor of the foot. The preferred treatment is wide resection.
REFERENCES: Hughes LE, Horgan K, Taylor BA, Laidler P: Malignant melanoma of the hand and foot: Diagnosis and management. Br J Surg 1985;72:811-815.
Fortin PT, Freiberg AA: Malignant melanoma of the foot and ankle. J Bone Joint Surg Am 1995;77:1396-1403.

Question 19

A 35-year-old man sustained a 1-inch stab incision in his proximal forearm while trying to use a screwdriver 2 weeks ago. The laceration was routinely closed, and no problems about the incision site were noted. He now reports that he has been unable to straighten his fingers or thumb completely since the injury. Clinical photographs shown in Figures 30a and 30b show the man passively flexing the wrist. What is the most appropriate management?

Explanation

DISCUSSION: The clinical photographs indicate that the tenodesis effect of digit flexion with passive wrist extension and digit extension with passive wrist flexion is intact, indicating no discontinuity of the extensor or flexor tendons. The most likely injury is a laceration of the posterior interosseous nerve.
REFERENCE: Feldon P, Terrono AL, Nalebuff EA, et al: Rheumatoid arthritis and other connective tissue diseases, in Green DP, Hotchkiss RN, Pederson WC, et al (eds): Green’s Operative Hand Surgery, ed 5. Philadelphia, PA, Elsevier, 2005, p 2069.

Question 20

A 55-year-old male sustained the injury in Figure A. His injury was complicated by an acute compartment syndrome. He underwent external fixation of his extremity and four compartment fasciotomy. When should the treatment shown in Figure B be performed to minimize the risk of infection?

Explanation

OrthoCash 2020

Question 21

A 63-year-old woman is seen 10 weeks after sustaining a closed minimally displaced distal radius fracture. She has been in a short-arm cast and reports minimal pain but notes that she is having difficulty using her thumb. An extensor pollicis longus (EPL) tendon rupture is suspected. Which examination finding would confirm lack of EPL function?

Explanation

EXPLANATION:
As many as to 5% of patients with a nondisplaced distal radius fracture experience EPL rupture. The extensor pollicis brevis (EPB) tendon often attaches to the extensor hood and sometimes continues more distally, providing weak metacarpophalangeal extension even in the setting of EPL disruption. However, because of the vector of its pull, the EPB cannot extend the thumb dorsal to the plane of the palm. A positive Froment sign is noted when flexion of the thumb interphalangeal joint with an attempted key pinch is caused by adductor pollicis weakness from ulnar nerve dysfunction. Compression of the median nerve in the carpal tunnel affects the recurrent motor branch of the abductor pollicis brevis, leading to thenar atrophy. The flexor pollicis longus tendon (FPL) is intact so the patient would not have difficulty flexing the thumb with the palm flat.

Question 22

-What gene is implicated in spinal muscular atrophy?

Explanation

Question 23

A 66-year-old man reports a 2-week history of worsening low back and leg pain. He reports that his pain is aggravated by lying down and relieved by standing and walking. He notes that he has been losing weight recently and that his pain has been awakening him during the night. His medical history is significant for hypertension, coronary artery disease, and prostate cancer. His physical examination is essentially unremarkable. Lumbar radiographs are within normal limits. What is the most appropriate management for this patient?

Explanation

DISCUSSION: In the initial assessment of acute low back pain in adults, no diagnostic testing is indicated during the first 4 weeks in the absence of “red flags” for a serious underlying condition. The purpose of the initial assessment of acute low back pain in adults is to rule out serious underlying conditions presenting as low back pain. The Agency for Healthcare Policy and Research, in its 1994 clinical practice guideline, identified four serious conditions that may present with low back pain, including fracture, tumor, infection, and cauda equina syndrome. This patient has five “red flags” for a spinal tumor as a possible etiology of his low back pain, including age of older than 50 years, constitutional symptoms (recent weight loss), pain worse when supine, severe nighttime pain, and a history of cancer. Of these, his history of cancer is most significant, as greater than 90% of spinal tumors are metastatic. In order of frequency, breast, prostate, lung, and kidney make up approximately 80% of all secondary spread to the spine. In the presence of “red flags” for tumor or infection, it is recommended that the clinician obtain a CBC count, ESR, and a urinalysis. If these are within normal limits and suspicions still remain, consider consultation or seek further evidence with a bone scan, radiographs, or additional laboratory studies. Negative radiographs alone are insufficient to rule out disease. If radiographs are positive, the anatomy can be better defined with MRI.
REFERENCES: Agency for Health Care Policy and Research, Bigos SJ (ed): Acute Low Back Problems in Adults. Rockville, MD, US Department of Health and Human Services, AHCPR Publication 95-0642, Clinical Practice Guideline #14, 1994.
Gertzbein SD: Metastatic spine tumors, in Herkowitz HN, Dvorak J, Bell G, et al (eds): The Lumbar Spine, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 792-802.

Question 24

Which of the following factors is most likely to be associated with prolonged survival of total knee arthroplasty?

Explanation

DISCUSSION: In a survivorship study of 9,200 total knee arthroplasties, Rand and Ilstrup identified four independent variables associated with a significantly lower risk of failure: primary total knee arthroplasty, diagnosis of rheumatoid arthritis, age of 60 years or older, and use of a condylar prosthesis with a metal-backed tibial component. Other clinical studies report the use of a posterior stabilized prosthesis to be comparable to a total condylar prosthesis with retained posterior cruciate ligament.
REFERENCES: Rand JA, Ilstrup DM: Survivorship analysis of total knee arthroplasty: Cumulative rates of survival of 9200 total knee arthroplasties. J Bone Joint Surg Am 1991;73:397-409.
Stern SH, Insall JN: Posterior stabilized prosthesis: Results after follow-up of nine to twelve years. J Bone Joint Surg Am 1992;74:980-986.
Knutson K, Lindstrand A, Lidgren L: Survival of knee arthroplasties: A nation-wide multicentre investigation of 8000 cases. J Bone Joint Surg Br 1986;68:795-803.

Question 25

Figures 177a and 177b are the radiographs of a 7-year-old boy with spastic cerebral palsy. He has quadriparetic involvement and is unable to ambulate. He has very limited abduction, 30 degrees of flexion contractures, and pain on abduction. Bilateral varus osteotomies are scheduled with acetabular procedures to improve stability. Which type of acetabular osteotomy should be performed?

Explanation

Question 26

A 53-year-old woman reports a 4-month history of gradual onset diffuse shoulder pain and limited function. She has had no prior treatment, and her medical history is unremarkable. Examination reveals globally painful active range of motion to 120 degrees forward elevation, 25 degrees external rotation with the arm at the side, and internal rotation to the sacrum. Passive range of motion is also limited in comparison with the contralateral shoulder. Radiographs are shown in Figures 31a through 31c. What is the most appropriate management? Review Topic

Explanation

The patient has stage II adhesive capsulitis. Patients most commonly affected are women between the ages of 40 and 60, and most cases are considered idiopathic. The preferred method of treatment is an intra-articular corticosteroid injection to decrease inflammation in the joint and allow for a gentle stretching therapy program. Sling immobilization is contraindicated because it likely will promote further joint contracture and prolonged recovery. Aggressive capsular stretching in the early stages of the disease is often counterproductive, unless pain can be adequately controlled with medication or injections. Manipulation under anesthesia and arthroscopic surgical treatment are used when symptoms remain refractory despite initial nonsurgical management.

Question 27

Figure 1 is the T2 coronal MRI scan(Massive atraumatic rotator cuff tear) of a 52-year-old woman with a 6-month history of shoulder pain. She does not recall a history of trauma. Physical therapy is recommended. What is the most significant predictor of failure of nonoperative treatment?

Explanation

The MRI reveals a large full thickness supraspinatus tear. A large, prospective study showed that physical therapy can be effective in the treatment of atraumatic full-thickness rotator cuff tears. Patient expectations regarding the role of rehabilitation were the strongest predictor of surgery. Other factors associated with surgery were higher activity level and not smoking. Anatomic features of the rotator
cuff tear and the severity of patient’s reported pain did not predict failure of nonoperative treatment. Patients who have low expectations regarding the effectiveness of physical therapy are more likely to fail nonoperative treatment.

Question 28

A 7-year-old boy is seen for follow-up for a scoliotic deformity. His parents are concerned because his deformity seems to have increased. He has no pain and is neurologically intact. A radiograph is shown in Figure 94, and measurement of his curve reveals that it has increased 10 degrees. What is the most appropriate recommendation for this patient at this time?

Explanation

DISCUSSION: Nakamura and associates have reported good results in patients with resection for hemivertebra-related congenital scoliosis who have a progression of their deformity. Because of the progression, observation is not appropriate for this patient’s deformity. Bracing has not been shown to alter the progression of congenital scoliosis. The “growing rod” technique is also not effective in preventing progression related to hemivertebra. Distraction instrumentation carries an increased risk of neurologic complications in children with congenital spine deformities. Progression after posterior arthrodesis alone can occur through the so-ca led “crankshaft phenomenon.”
REFERENCES: Nakamura H, Matsuda H, Konishi S, et al: Single-stage excision of hemivertebrae via the posterior approach alone for congenital spine deformity: Follow-up period longer than ten years.
Spine 2002;27:110-115.
Ruf M, Harms J: Posterior hemivertebra resection with transpedicular instrumentation: Early correction in children aged 1 to 6 years. Spine 2003;15:2132-2138.

Figure 95a Figure 95b Figure 95c Figure 95d

Question 29

Triple arthrodesis in a reduced position

Explanation

What percentage of the human genome represents the actual genes:

Question 30

Initial repair of the large U-shaped rotator cuff tear shown in Figure 12 consists of closing the tear side-to-side to take advantage of margin convergence. The most significant biomechanical consequence of this repair step results in

Explanation

DISCUSSION: Margin convergence refers to the phenomenon that occurs with side-to-side closure of large U- or L-shaped rotator cuff tears in which the free margin of the tear converges toward the greater tuberosity as the side-to-side tear progresses. The creation of the converged cuff margin creates decreased strain in the free margin of the repaired cuff, resulting in a decreased strain in the repair sutures. While the size of the humeral head defect is made smaller with side-to-side closure, biomechanically, this is less significant. The mild increase in thickness of the repair at the side-to-side margin is less important than a reduction in stress in the repaired tissue. Stress in the crescent cable region of the cuff actually increases and becomes more physiologic in transmitting force from the cuff to the greater tuberosity.
REFERENCES: Burkhart SS: A stepwise approach to arthroscopic rotator cuff repair based on biomechanical principles. Arthroscopy 2000;16:82-90.
Burkhart SS, Athanasiou KA, Wirth MA: Margin convergence: A method of reducing strain in massive rotator cuff tears. Arthroscopy 1996;12:335-338.

Question 31

-Images from an MRI scan of this patient’s left hip are shown in Figure 30c through 30e. What is the most likely cause of his acute pain?

Explanation

DISCUSSION FOR QUESTIONS 30 THROUGH 32
This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of longstanding groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement.Surgical treatment for cam impingement can be effective for symptomatic patients. Even among highlevel athletes, open surgical dislocation of the hip has been shown to have good results. Most patients with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable to those realized with open surgical dislocation. The literature describes success in terms of athletes returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment.Byrd and Jones described 5 patients who developed transient neurapraxias that resolved uneventfully.The patients in his series who had concomitant microfracture had a 92% return to sports within the follow-up period. Cam impingement has long been thought to be associated with a history of a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who underwent a periacetabular osteotomy can develop a more retroverted acetabulum as well.

Question 32

A 10-year-old boy with an L1 myelomeningocele has a low-grade fever and a swollen thigh that is warm to touch and erythematous. AP and lateral radiographs are shown in Figures 24a and 24b. Management should consist of

Explanation

DISCUSSION: Fractures of the long bones are common in patients with myelodysplasia, and the frequency of fracture increases with higher level defects. Fractures also occur following surgery and immobilization secondary to disuse osteoporosis. The response to the fracture (swelling, fever, warmth, erythema) is often confused with infection, osteomyelitis, or cellulitis. Management should consist of a short period of immobilization in a well-padded splint. Long-term casting results in further osteopenia and repeated fractures.
REFERENCES: Lock TR, Aronson DD: Fractures in patients who have myelomeningocele. J Bone Joint Surg Am 1989;71:1153-1157.
Kumar SJ, Cowell HR, Townsend P: Physeal, metaphyseal, and diaphyseal injuries of the lower extremities in children with myelomeningocele. J Pediatr Orthop 1984;4:25-27.

Question 33

An 11-year-old boy reports the acute onset of elbow pain and swelling after pushing his brother. The patient's mother and a younger sibling have experienced numerous fractures. You note that the patient and his mother have blue sclera and normal-appearing teeth. A radiograph of the elbow is shown in Figure 60. This patient's disorder is most likely the result of Review Topic

Explanation

Osteogenesis imperfecta (OI) is a genetically determined disorder of type I collagen synthesis characterized by bone fragility. This patient sustained a displaced fracture of the olecranon apophysis after relatively minor trauma. Physical examination reveals distinctly blue sclera. His mother and younger sibling have experienced numerous fractures suggesting a family history of bone fragility. The patient's history, clinical features, and family history are consistent with a diagnosis of Sillence type I-A OI. Type I OI is the mildest and most common form. Inheritance is autosomal dominant.
Type I is subclassified into the A type (absence of dentinogenesis imperfecta) and B type (presence of dentinogenesis imperfecta). These individuals have blue sclerae, and although the initial fracture usually occurs in the preschool years, it may occur at any age. Furthermore, olecranon apophyseal fractures that occur after relatively minor trauma have been associated with type I OI. Cells from individuals with type I OI largely demonstrate a quantitative defect of type I collagen; they synthesize and secrete about half the normal amount of type I procollagen. In this patient, there are no indications that the child has been subjected to abuse. Radiographs of the elbow show no evidence of osteopetrosis (due to abnormal osteoclast function) or rickets (due to a deficiency of vitamin D). Morquio syndrome (characterized by a defect of the enzyme N-Ac-Gal-6 sulfate sulfatase) is not associated with blue sclera.

Question 34

Figures 25a and 25b show the radiographs of a 66-year-old man who has had a long history of bilateral painful flatfoot deformities. Examination reveals that his foot is partially correctable passively, albeit with discomfort, and he has an Achilles tendon contracture. An ankle-foot orthosis has failed to provide relief. Treatment should now consist of

Explanation

DISCUSSION: The patient has a pronounced deformity with pain and degenerative arthritis; therefore, triple arthrodesis is the treatment of choice. Gastrocnemius or Achilles tendon lengthening may be a necessary adjunct to the triple arthrodesis, but alone is inadequate to allow for correction. Because the ankle-foot orthosis has failed to provide relief, a UCBL is not likely to help. Osteotomy procedures are designed for lesser deformities and well-preserved joints.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004,

pp 115-120.
Walling AK: Symposium: Adult acquired flatfoot. Clin Orthop 1999;365:2-99.

Question 35

Figure 37 shows the radiograph of a 21-year-old collegiate basketball player who has had mild midfoot aching for the past 4 months. What is the best course of action?

Explanation

DISCUSSION: A stress fracture of the navicular is considered a high-risk injury because of the incidence of nonunion. If identified early, cast immobilization with no weight bearing is appropriate. However, this patient is a high-caliber athlete who has had symptoms for 4 months. Therefore, surgery is recommended to expedite recovery and optimize the chance of healing.
REFERENCES: Meyer SA, Saltaman CL, Albright JP: Stress fractures of the foot and ankle. Clin Sports Med 1993;12:395-413.
Kahn JM, Fuller PJ, Burkner PD, et al: Outcome of conservative and surgical management of navicular stress fractures in athletes: Eighty-six cases proven with computerized tomography. Am J Sports Med 1992;20:657-666.
Fitch KD, Blackwell JP, Gillmour WN: Application for non-union stress fractures of the tarsonavicular. J Bone Joint Surg Br 1989;71:105.

Question 36

What spinal nerves in the cauda equina are primarily responsible for innervation of the bladder?

Explanation

DISCUSSION: The spinal nerves primarily responsible for bladder function are the S2, S3, and S4 nerve roots. With significant compression of the cauda equina by either disk herniation, tumor, or degenerative stenosis, bladder dysfunction may result.
REFERENCES: Hoppenfeld S: Physical Examination of the Spine and Extremities. Norwalk, CT, Appleton-Century-Crofts, 1976, p 254.
Pick TP, Howden R (edS): Gray’s Anatomy. New York, NY, Bounty Books, 1977, p 1004.

Question 37

A 20-year-old elite college football player has ecchymosis, swelling, and pain on the lateral side of his foot after a game. Radiographs are shown in Figures 31a through 31c. Management should consist of

Explanation

DISCUSSION: Metaphyseal-diaphyseal junction fractures of the fifth metatarsal require careful evaluation. In athletes, early intervention with a 4.5-mm intramedullary screw correlates with an earlier return to activity. One study examining the failure of surgically managed Jones fractures revealed that use of anything other than a 4.5-mm malleolar screw for internal fixation correlated with failure.
REFERENCES: Glasgow MT, Naranja RJ Jr, Glasgow SG, et al: Analysis of failed surgical management of fractures of the base of the fifth metatarsal distal to the tuberosity: The Jones fracture. Foot Ankle Int 1996;17:449-457.
Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 243-252.

Question 38

Which of the following patients has the highest risk of developing recurrent instability after an arthroscopic Bankart procedure for anterior shoulder instability? Review Topic

Explanation

The 18-year old competitive tennis player with no ligamentous laxity and x-ray findings consistent with a Hill-Sachs lesion and loss of glenoid contour has an instability severity index score (ISIS) of 9, which is associated with a >70% chance of recurrent instability after a arthroscopic Bankart procedure.
The surgical management of anterior shoulder instability consists of both arthroscopic and open approaches. The guiding principles for treatment are the restoration of the normal glenoid labrum anatomy and retensioning of the inferior glenohumeral ligament which is achieved via soft-tissue reconstructions (repair of any labral detachment +/- capsular shift) or bony procedures (such as transfer of the coracoid process).
Ahmed et al. reviewed 302 patients who had undergone arthroscopic Bankart repair and capsular shift for the treatment of recurrent anterior glenohumeral instability. The prevalence of patient and injury-related risk factors for recurrence was assessed. The rate of recurrent glenohumeral instability after arthroscopic Bankart repair and capsular shift was 13.2%. The risk of recurrence was independently predicted by the patient’s age at surgery, the severity of glenoid bone loss, and the presence of an engaging Hill-Sachs lesion.
Balg et al. identified risk factors for recurrent instability after arthroscopic Bankart procedure in 131 consecutive patients. Age under 20 years at the time of surgery; involvement in competitive or contact sports or those involving forced overhead activity; shoulder hyperlaxity; a Hill-Sachs lesion present on an AP radiograph of the shoulder in external rotation and/or loss of the sclerotic inferior glenoid contour were all identified as risk factors. These factors were integrated into a 10-point preoperative instability severity index score (ISIS). Patients with a score over 6 points had an unacceptable recurrence risk of 70%.
Illustration A summarizes the components of the ISIS as developed by Balg and Boileau.
Incorrect Answers:

Question 39

What is the next most appropriate step in the orthopaedic management of this patient?

Explanation

Posterior column with articular impaction and a free fragment
Anterior column with articular impaction
Posterior wall with an intra-articular fragment
Posterior wall with articular impaction and a free intra-articular fragment
Posterior wall with articular impaction Corrent answer: 4
The CT scan shows a posterior wall fracture with impaction of the articular surface and a free fragment within the joint. Proper treatment of this injury requires not only reduction and fixation of the posterior wall fragment but also removal of the free fragment and elevation of the depressed articular segment.
OrthoCash 2020
A 28-year-old female firefighter fell from the top of a three-story building in the line of duty. She sustained a displaced pelvic fracture with more than 5 mm displacement. Compared to normal healthy controls, these patients have a higher incidence of
normal sexual function and normal vaginal childbirth.
sexual dysfunction (dyspareunia) and normal vaginal childbirth.
normal sexual function and caesarean section childbirth.
sexual dysfunction (dyspareunia) and caesarean section childbirth.
normal sexual function and caesarean section childbirth until hardware removal.
Pelvic trauma in women has been shown to increase the risk of sexual dysfunction and dyspareunia. Additionally, caesarean section childbirth is
almost universal following pelvic trauma regardless of whether anterior pelvic hardware is present or not.
OrthoCash 2020
A 30-year-old man falls off a 7-foot ladder and sustains the injury seen in the radiograph and the CT scan shown in Figures 39a and 39b. Medical history is negative. Management of this injury should include which of the following?

Closed treatment and casting
Open reduction and internal fixation
Primary subtalar arthrodesis
Percutaneous fixation
External fixation
A Sanders type 2 intra-articular calcaneus fracture in a young healthy nonsmoker is best treated with open reduction and internal fixation. Whereas nonsurgical management is an option, Buckley and associates have shown that these fractures have a better outcome with surgical care. Percutaneous fixation is reserved for tongue-type fractures and subtalar arthrodesis is used in some type 4 fractures. External fixation has not been shown to be advantageous in closed fractures.
OrthoCash 2020
A 24-year-old woman fell from a horse and landed on her outstretched right arm. Radiographs reveal an elbow dislocation with a type II coronoid fracture and a nonreconstructable comminuted radial head fracture. What is the most appropriate management?
Radial head resection, open reduction and internal fixation of the coronoid, and medial collateral ligament repair
Radial head resection and lateral collateral ligament repair
Radial head arthroplasty alone
Radial head arthroplasty and lateral collateral ligament repair
Radial head arthroplasty, open reduction and internal fixation of the coronoid, and lateral collateral ligament repair
The combination of an elbow dislocation and a fracture of the radial head and coronoid is known as a terrible triad injury. To restore elbow stability, each injury must be addressed. The nonreconstructable radial head fracture requires implant arthroplasty. Open reduction and internal fixation of the coronoid is also necessary as is repair of the lateral collateral ligament complex which is usually avulsed from the lateral epicondyle region.
OrthoCash 2020
A 30-year-old man is brought to the emergency department after a motor vehicle accident. He has a closed midshaft femoral fracture and an intra-abdominal injury. He is currently in the operating room and the exploration of his abdomen has been completed. His initial blood pressure was 70/30 mm Hg and is now 90/50 mm Hg after 4 liters of fluid and 2 units of blood. His initial serum lactate was 3.0 mmol/L (normal < 2.5), 1 hour postinjury it was 3.5 mmol/L, and it is now 5 mmol/L. His core temperature is 93 degrees F (34 degrees C).
What is the most appropriate management for the femoral shaft fracture at this point?
Reamed intramedullary nailing
Traction
External fixation
Open plating
Mast suit
The patient has several indications that he is not ready for definitive fixation of the femoral shaft fracture at this point. He is cold with a core temperature of 93 degrees F, and hypothermia of less than 95 degrees F (35 degrees C) has been shown to be associated with an increased mortality rate in trauma patients. The patient has also not been resuscitated based on his increasing lactate levels and although controversial, it has been shown that temporary external fixation leads to a lower incidence of multiple organ failure and acute respiratory distress syndrome.
OrthoCash 2020
A 45-year-old male karate instructor sustained the injury shown in Figures 40a through 40c while practicing karate. The decision to proceed with surgery depends on which of the following factors?

MRI scan
Physical examination
Workers’ compensation status
Surgeon availability
Patient age
The most important criteria in determining the need for surgery following a nondisplaced or minimally displaced tibial plateau fracture is knee stability to varus/valgus stress. Soft-tissue injury noted on MRI may be addressed at a later time following fracture healing. This fracture pattern is amenable to nonsurgical management. Decisions regarding surgical intervention may be made up to 2 weeks after injury.
OrthoCash 2020
A 32-year-old man has a Glasgow Coma Scale score of 8 and an open pelvic fracture. The patient’s family reports that he is a Jehovah’s Witness. Initial hemodynamic instability has resolved. In the operating room during a washout, the patient’s blood pressure becomes unstable. What is the most appropriate action?
Consult the ethics committee before giving blood.
Use cell saver blood.
Ask the patient’s family for consent to give blood.
Use plasma expanders.
Give the patient blood.
Certain medical procedures involving blood are specifically prohibited in the belief system of a Jehovah’s Witness whereas others are not doctrinally prohibited. For procedures where there is no specific doctrinal prohibition, a Jehovah’s Witness should obtain the details from medical personnel and make his or her own decision. Transfusions of allogeneic whole blood or its constituents or preoperative donated autologous blood are prohibited. Other procedures, while not doctrinally prohibited, are not promoted such as hemodilution, intraoperative cell salvage, use of a heart-lung machine, dialysis, epidural blood patch, plasmapheresis, white blood cell scans (labeling or tagging of removed blood returned to the patient), platelet gel, erythropoietin, or blood substitutes. The patient should not be given blood. Plasma expanders should be used first to restore hemodynamic stability. Cell saver blood from an open wound is not recommended nor would there likely be enough from an open pelvic fracture to salvage. The patient’s family may be expressing their own beliefs rather than the patient’s beliefs and it would be better to ask the patient when he or she is more alert to determine what procedures they would allow. A consult with the ethics committee will unnecessarily delay an intervention that should restore hemodynamic stability.
OrthoCash 2020
Figure 50 shows the radiograph of a 26-year-old man who sustained an isolated open injury to his foot. Examination reveals no gross contamination in the wound. There is a palpable dorsalis pedis pulse and sensation is present on the dorsal and plantar aspects of the foot. Initial treatment should consist of wound debridement, antibiotics, and

talectomy.
reimplantation of the talus.
reimplantation of the talus with acute triple arthrodesis.
Syme amputation.
transtibial amputation.
The radiograph shows a complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful, and provides for flexibility with any future reconstructive procedures.
OrthoCash 2020
Which of the following long bone fracture patterns occurs after a pure bending force is exerted to the bone?
Spiral
Oblique
Transverse
Segmental
Comminuted
A pure bending force produces a transverse fracture pattern. Spiral fractures are mainly rotational, oblique are uneven bending, segmental are four-point bending, and comminuted are either a high-speed torsion or crush mechanism.
OrthoCash 2020
A 38-year-old woman fell from a ladder onto her right hip. The radiographs and CT scan are shown in Figures 52a through 52d. What is the best surgical approach for this fracture?

Kocher-Langenbeck
Iliofemoral
Ilioinguinal
Extended iliofemoral
Triradiate approach
The fracture is an associated both column fracture. The best approach for this fracture is the ilioinguinal. The Kocher-Langenbeck is best for posterior injuries to the acetabulum and some transverse fractures. The iliofemoral alone is limited to high anterior column injuries. The extended iliofemoral and triradiate
approaches although useful for this fracture, have a higher rate of complications.
OrthoCash 2020
An otherwise healthy 26-year-old woman is involved in a high speed motor vehicle accident and sustains the injury shown in Figure 54 to her dominant right arm. Appropriate treatment of this injury complex includes

plating of the radial shaft fracture then open repair of the triangular fibrocartilage complex.
open reduction and internal fixation of the radius and ulna.
plating of the radius then closed reduction and evaluation of the distal radioulnar joint (DRUJ).
closed reduction of the radius and DRUJ.
plating of the radius then pinning of the DRUJ in pronation.
This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.
OrthoCash 2020
A 40-year-old laborer sustains the injury shown in the radiograph and CT scan in Figures 56a and 56b. What is the most common complication associated with surgical intervention?

Chronic osteomyelitis
Planovalgus hindfoot
Plantar nerve entrapment
Wound dehiscence
Painful hardware
The patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence.
OrthoCash 2020
Patients in compensated shock (normal vital signs) are thought to be at risk for which of the following?
A primed immune system with an increased risk of a systemic inflammatory response
Nothing since they are no longer in uncompensated shock and their vital signs have normalized
Higher nonunion rates after fracture fixation
Higher infection rates after definitive fracture fixation
Higher complication rates after temporizing external fixation of long bone fractures
Patients who are in compensated shock have normal vital signs but still have hypoperfusion of organ beds such as the splanchnic circulation due to preferential perfusion of the heart and brain. The response to this continued hypoperfusion may be the development of a systemic inflammatory response that may lead to multiple organ failure. The patients are thought to be at risk for a “primed” immune system due to the ongoing stimulation of the immune system and may have an exaggerated response to a second stimulus such as surgery or infection. Other markers of resuscitation should be used besides vital signs to determine when resuscitation has been completed. The use of temporizing fixation has been shown to lower systemic complication rates, and the infection and union rate after staged fixation is not altered.
OrthoCash 2020
A 14-year-old boy sustains a right leg injury after being thrown from his motorcycle while racing. He reports diffuse right leg pain starting at his knee and proceeding distally to include his foot. After the injury the patient’s mother reports the tibia moving posteriorly then anteriorly while she was supporting the leg. In the emergency department 4 hours after injury, examination reveals a large knee effusion, firm compartments of the leg, a palpable posterior tibialis pulse with a warm, pink foot, and capillary refill of 2 seconds at the toes. His blood pressure is 100/50 mm Hg. Motor examination is
intact, but there is decreased sensation in the dorsal first interspace and plantar aspect of the foot. Compartment pressure measurement reveals all four compartments with pressures of 33, 36, 33, and 38 mm Hg respectively. Radiographs are shown in Figure 59a and 59b. The remainder of the skeletal examination is normal. What is the optimal management for this injury?

Emergent four compartment fasciotomies
Emergent four compartment fasciotomies and open reduction and internal fixation of the fracture
Elevation of the limb overnight and four compartment fasciotomies in the morning
Elevation of the limb overnight and a recheck of compartment pressures in the morning
Emergent MRI of the knee and leg Corrent answer: 2
The patient has a compartment syndrome based on the firm compartments of the leg and the elevated compartment pressures measured at the diastolic pressure reading. Muscle ischemia occurs quickly when compartment pressures are elevated, and within 6 hours irreversible damage can occur. Emergent fasciotomies permit decompression of all four compartments and reestablishment of vascular supply to the muscles. Stabilization of the fracture prevents further soft-tissue injury.
OrthoCash 2020
Resuscitation of a trauma patient who has been in hypovolemic shock is complete when which of the following has occurred?
The mean arterial blood pressure is above 90 mm Hg.
The pulse pressure has normalized.
Urine output is greater than 0.5 to 1 mL/kg/h.
Oxygen delivery has been maximized.
Aerobic metabolism has been restored in all tissue beds.
Shock can be defined as inadequate tissue perfusion. Resuscitation or the resolution of shock is defined as when oxygen debt has been repaid, tissue acidosis is eliminated, and aerobic metabolism has been restored in all tissue beds. The end points for resuscitation are not clearly defined, but occult shock can still be present in the setting of normal vital signs and normal urine output due to selective perfusion of organ systems.
OrthoCash 2020
A 12-year-old girl falls in gymnastics and sustains comminuted midshaft radius and ulna fractures. Closed reduction and cast immobilization are attempted but fracture redisplacement with 20 degrees of angulation occurs. Surgical treatment includes closed reduction and intramedullary fixation of both bones. What is the most common long-term complication for this fracture?
Infection
Malunion
Loss of forearm rotation
Refracture
Delayed union/nonunion
Healing of forearm fractures in skeletally immature patients is the usual outcome. The use of intramedullary fixation has been reported to result in a lower frequency of refractures when compared to plate osteosynthesis due to the absence of diaphyseal holes after plate removal, which are considered stress risers. Regardless of implant technique, malunion and infection are infrequent. Loss of forearm pronation and supination is a common occurrence in surgically treated fractures due to the higher degree of soft-tissue injury, and periosteal stripping leads to fracture site instability and fracture comminution.
OrthoCash 2020
The teardrop shape marked with an asterisk in Figure 61 represents what anatomic structure?

Anterior superior iliac spine
Sciatic buttress
A column of bone running from the anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)
The most superior portion of the roof of the acetabulum
Iliopectineal line
The teardrop can be visualized on the obturator outlet view of the pelvis and represents a thick column of bone that runs from the AIIS to the PSIS. Half pins for eternal fixation frames or screws can be inserted into this column for fixation of fractures.
OrthoCash 2020
A patient was treated with a revision reamed intramedullary nail for a nonunion 6 months ago. A current radiograph is shown in Figure

Question 40

During a posterior cruciate ligament (PCL)-retaining total knee arthroplasty, a critical principle to remember is to

Explanation

DISCUSSION:
Maintenance of the joint line and accurately tensioning the PCL are critical in the proper execution of a PCL-retaining total knee arthroplasty. Appropriate tension helps ensure femoral rollback and avoid stiffness or instability. Raising the joint line to help ensure full extension should be avoided in cruciate- retaining knees, because doing so creates an unfavorable kinematic environment. The three important principles of surgical technique needed to maintain appropriate tensioning of the PCL include 1) choosing the proper femur size to reproduce the native femoral anterior/posterior dimension, 2) reproducing the joint line by resecting as much tibia from the healthy side as will be replaced by the smallest thickness of the tibial component and, 3) ensuring that full extension is achieved by soft-tissue releases and not by taking additional distal femur, as may be done in a posterior stabilized approach. Another important principle is to re-create the natural degree of the patient’s posterior tibial slope to avoid tightness in
flexion.

Question 41

Figure 59 shows properties of a material being tested for use as an implant. What is represented by the portion of the stress-strain curve from point A to point B?

Explanation

DISCUSSION: The figure is a stress-strain diagram representing specific metal subjected to increasing tensile stress. The portion of the curve from A to B is a straight line demonstrating a proportional increase in strain for each increase in tensile stress. If the stress is removed at any point between A and C, the material will return to its original shape, returning back along the original curve without permanent deformation. This is termed elastic behavior. If the applied stress causes strain beyond point C, then permanent deformation occurs and returns along a different path to a different zero stress point. This is termed plastic behavior. The point C at which the material stops behaving in an elastic manner and begins behaving in a plastic manner is the elastic limit or yield point. Point D represents a point on the curve of plastic deformation. Point E is the fracture point when the stress on the material creates enough strain that the material fractures.
REFERENCES: Vaccaro AR (ed): Orthopaedic Knowledge Update 8. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2005, pp 45-46.
El-Ghannam A, Ducheyne P: Biomaterials, in Mow VC, Huiskes R (eds): Basic Orthopaedic Biomechanics and Mechano-Biology, ed 3. Philadelphia, PA, Lippincott-Raven, 2005, pp 501-503.

Question 42

Your 25-year-old patient complains of anterior knee pain after retrograde femoral nailing for a diaphyseal fracture and asks you why you didn’t perform antegrade nailing as he has seen on the internet. You tell him that retrograde nailing is your preferred technique over antergrade nailing for diaphyseal femoral fractures because it has been shown to have?

Explanation

DISCUSSION: Patients with retrograde femoral nails commonly have knee pain, while antegrade nails commonly have hip pain, abductor weakness and heterotopic ossification of the abductors. Ostrum’s randomized prospective study of 100 patients with reamed femoral nails found 22% of antegrade nail patients had proximal hip pain, weak hip abductors or trendelenburg gait. No significant difference was found in set-up time, operative time, knee motion or pain, or infection rates. Ricci performed a retrospective study of 293 fractures and found that the antegrade femoral nail group had more hip pain (10% vs 4%) and the retrograde nail group had more knee pain (36% vs 9%). There was no difference in healing, malunion, non-union or other complications. Tornetta performed a randomized controlled comparison of 69 femur fractures and found more problems of length and rotation using a retrograde nailing. There was no difference in time to union, operating time, blood loss, complications, size of nail or reamer, or transfusion requirements

Question 43

A 75-year-old patient returns for follow-up after undergoing bilateral total hip arthroplasty (THA). The right hip is a hybrid THA performed 12 years ago, whereas the left hip is a cementless THA performed 10 years ago. Both acetabular components are the same type, same size, and from the same manufacturer. Both femoral heads are 28-mm cobalt-chromium components. What is the most likely explanation for the advanced polyethylene wear in one hip?

Explanation

DISCUSSION: Over the past three decades, gamma irradiation and air has been the most common method of sterilizing polyethylene used in total joint arthroplasty. This method of sterilization results in breakage of the chemical bonds within the polymer. While this promotes cross-linking, it also leaves the polyethylene vulnerable to oxidation, especially if packaged in an air environment. Oxidation has been shown to decrease polyethylene’s molecular weight, ultimate tensile strength, elongation, and toughness which results in a stiffer, more brittle material that is less resistant to wear. Severity of oxidation and a decrease in mechanical properties have been shown to be related to the length of time that the component is exposed to air (the shelf life). Currier and associates studied the clinical performance of gamma irradiated in air polyethylene components that had been shelf aged. They demonstrated that for the first

5 years of shelf life, polyethylene oxidized rather slowly. However, polyethylene components with a shelf life of more than 5 years would be expected to have minimal mechanical toughness and would likely fail rapidly if implanted. Bohl and associates evaluated 135 patients who had undergone total knee arthroplasty. Survivorship at 5 years was 100% for components with a shelf life of less than 4 years, 89% for components with a shelf life of 4 to 8 years, and 79% for components with a shelf life of more than 8 years. Sychterz and associates reported no correlation between shelf life and true wear rates for components with a shelf life of less

than 3 years. In summary, both in vivo and in vitro data suggest that shelf life in excess of

3 to 5 years has a direct effect on wear of polyethylene.
REFERENCES: Currier BH, Currier JH, Collier JP, et al: Shelf life and in vivo duration: Impacts on performance of tibial bearings. Clin Orthop 1997;342:111-122.
Bohl JR, Bohl WR, Postak PD, et al: The Coventry Award: The effects of shelf life on clinical outcome for gamma sterilized polyethylene tibial components. Clin Orthop 1999;367:28-38.
Sychterz CJ, Young AM, Orishimo K, et al: The relationship between shelf life and in vivo wear for polyethylene acetabular liners. J Arthroplasty 2005;20:168-173.

Question 44

A 20-year-old athlete sustains a 2- x 3-cm grade IV chondral injury to the right knee. After failure of nonsurgical management, which of the following procedures would ensure the highest percentage of hyaline-like cartilage?

Explanation

DISCUSSION: Autologous chondrocyte implantation was first reported by Brittberg in 1994 and has resulted in predominantly type II collagen (hyaline-like articular cartilage) in the repair tissue. The extracellular matrix in articular cartilage is made up primarily of type II collagen, proteoglycans, and water. Arthroscopic chondroplasty, microfracture, drilling, and abrasion arthroplasty all result eventually in fibrocartilage fill of the defect (predominantly type I collagen).
REFERENCES: Brittberg M, Lindahl A, Nilsson A, et al: Treatment of deep cartilage defects in the knee with autologous chondrocyte transplantation. N Engl J Med 1994;331:889-895.
Garrett WE, Speer KP, Kirkendall DT (eds): Principles & Practice of Orthopaedic Sports Medicine. Philadelphia, PA, Lippincott Williams & Wilkins, 2000, pp 787-804.

Question 45

An elite gymnast injured her ankle in an awkward dismount 36 hours ago. Examination reveals weakness on single leg step-up. A clinical photograph of the medial ankle is shown in Figure 15. Plain radiographs are normal. To help confirm the diagnosis, the next step in evaluation should consist of

Explanation

DISCUSSION: Ecchymosis on the medial side of the ankle is distributed in the posterior tibialis tendon sheath location, posterior to the medial malleolus, and extending inferiorly to the tendon’s attachment on the navicular. MRI is the imaging study of choice to determine the extent of tendon damage. MRI will also help assess the deltoid ligament. Bone scans and CT are helpful in identifying osteochondral fractures and occult fractures; however, these studies are not indicated for this patient. Peroneal tendons are located lateral on the ankle. Arthroscopy of the ankle joint would not be helpful in assessing the posterior tibial tendons.
REFERENCES: Lutter LD, Mizel MS, Pfeffer GB (eds): Orthopaedic Knowledge Update: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1994, pp 307-317.
Rosenberg ZS, Cheung Y, Jahss MH, Noto AM, Norman A, Leeds NE: Rupture of the posterior tibial tendon: CT and MR imaging with surgical correlation. Radiology 1988;169:229-235.

Question 46

Which of the following methods most reliably detects mechanical loosening of the hip?

Explanation

DISCUSSION: Mechanical loosening of the hip is best revealed by serial radiographs of the prosthetic joint. None of the other methods of evaluation is considered reliable in diagnosing mechanical loosening.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 455-492.
Miniaci A, Bailey WH, Bourne RB, McLaren AC, Rorabeck CH: Analysis of radionuclide arthrograms, radiographic arthrograms, and sequential plain radiographs in the assessment of painful hip arthroplasty. J Arthroplasty 1990;5:143-149.

Question 47

A patient is treated with volar plating for a distal radius fracture. The CT scan shown in Figure 15 is obtained after union of the fracture because the patient reports ongoing symptoms. The prominent hardware is most likely injuring what tendon?

Explanation

DISCUSSION: Extensor tendon injuries have been reported after volar plating of distal radius fractures. The CT scan shows prominent dorsal hardware a few millimeters ulnar to Lister’s tubercle. The second compartment, the ECRL and ECRB, is radial to Lister’s tubercle. The ECU runs along the distal ulna. The contents of the fourth dorsal compartment run just ulnar to Lister’s tubercle. The EDC tendon is likely irritated in this patient. The EPB runs along the radial border of the radius and is well away from prominent hardware.
REFERENCES: Benson EC, Decarvalho A, Mikola EA, et al: Two potential causes of EPL rupture after distal radius volar plate fixation. Clin Orthop Relat Res 2006;451:218-222.
Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist: Diagnosis and Operative Treatment. Philadelphia, PA, Mosby-Year Book, 1998.

Question 48

-A 75-year-old woman fell at home and sustained the injury seen in Figures 249a through 249c. What is the most appropriate treatment option?

Explanation

Question 49

Figure 80a shows an arthroscopic view from an infralateral portal of a right knee. Figure 80b shows a coronal MRI scan, and Figures 80c through 80e show consecutive sagittal images of the knee. The images show what anatomic finding? Review Topic

Explanation

The arthroscopic view and the coronal MRI scan show a discoid lateral meniscus covering almost the entire lateral tibial plateau. The sagittal views show a contiguous meniscus or "bow tie" sign on three consecutive images, pathognomonic for a discoid meniscus. Lateral discoid menisci are much more common than medial. There is no evidence of abnormal signal to indicate meniscal tearing. A transverse meniscal ligament is best seen anterior to the anterior horn of the lateral meniscus on multiple views. There is no evidence of a loose body on the arthroscopic or MRI images.

Question 50

A purulent flexor tenosynovitis of the thumb may communicate with the small finger flexor through which of the following structures?

Explanation

DISCUSSION: Only the flexor sheaths of the thumb and small finger are continuous from the digit through the carpal canal and into the distal forearm. If one of the sheaths ruptures from synovitis, it may contaminate the other sheath through Parona’s space in the distal forearm. This potential space lies superficial to the pronator quadratus and deep to the flexor tendons.
REFERENCES: Green DP, Hotchkiss RN, Pederson WC (eds): Operative Hand Surgery, ed 4. New York, NY, Churchill Livingstone, 1999, pp 1044-1045.
Burkhalter WE: Deep space infections. Hand Clin 1989;5:553-559.

Question 51

A 64-year-old female sustains a nondisplaced distal radius fracture and undergoes closed treatment using a cast. Three months after the fracture she reports an acute loss of her ability to extend her thumb. What is the most likely etiology of her new loss of function?

Explanation

DISCUSSION: According to the referenced article by Jupiter and Fernandez, the most common scenario of extensor pollicis longus rupture after a distal radius fracture is when the fracture is non or minimally displaced. The hypothesis is that the rupture happens at an area of relative hypovascularity and healing callus can aggravate this area, leading to a degenerative tear. Hove et al reported an incidence of delayed tendon rupture after distal radius fracture of 0.3 percent. In their series of 18 extensor pollicis longus tendon ruptures, 15 were treated with tendon transfers. They reported good results: nearly 100% patient satisfaction, all patients were able to elevate the thumb to the level of the palm, and full independent index finger movements.

Question 52

Osteonecrosis of the humeral head is a rare complication seen after dislocation of the glenohumeral joint in skeletally immature patients. When this complication is encountered, treatment should consist of

Explanation

DISCUSSION: This rare complication occurs after fracture-dislocation and has been seen after surgical stabilization in the adolescent. In most reported cases, prolonged observation has been shown to result in revascularization.
REFERENCES: Pateder DB, Park HB, Chronopoulos E, et al: Humeral head osteonecrosis after anterior shoulder stabilization in an adolescent: A case report. J Bone Joint Surg Am 2004;86:2290-2293.
Wang P Jr, Koval KJ, Lehman W, et al: Salter-Harris type III fracture-dislocation of the proximal humerus. J Pediatr Orthop B 1997;6:219-222.

Question 53

A 22-year-old professional baseball catcher has posterior shoulder pain and severe external rotation weakness with the arm in adduction. Radiographs are normal. MRI scans are shown in Figures 15a through 15c. Management should consist of

Explanation

DISCUSSION: The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T₁-weighted MRI scans and with high signal intensity on T₂-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. MRI has the added advantage, compared with other imaging modalities, of detecting intra-articular lesions, such as labral tears, which are frequently associated with ganglion cysts of the shoulder. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear. Acromioplasty would not address the primary pathology in this patient.
REFERENCES: Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment.
J Bone Joint Surg Am 2000;82:415-424.
Martin SD, Warren RF, Martin TL, et al: Suprascapular neuropathy: Results of non-operative treatment. J Bone Joint Surg Am 1997;79:1159-1165.

Question 54

The lateral fragment of bone (Segond fracture) associated with an injury of the anterior cruciate ligament is the result of an avulsion of the

Explanation

The segond fragment is avulsed by three fibers which are under tension to this area at proximal lateral aspect of tibia. These fibers are intimate with lateral capsule consisting of 1) posterior fibers of anterolateral femoratibial ligament 2) the anterior expansion of arcuate ligament 3) biceps tendon expansions from posteriolateral direction.

Question 55

A 72-year-old woman falls onto her left hip after tripping over a curb during her daily 3-mile walk. An injury radiograph is shown in Figure A. What is the best long term solution?

Explanation

THA is the best long term solution for displaced femoral neck fractures (FNF) in active elderly patients.
The aims of surgery for FNF in elderly patients are immediate pain relief, rapid mobilization, and low complications and revision. THA has best pain relief, fewer reoperations, best survivorship and is most cost-effective but has longer operative/anesthetic time, blood loss, higher infection rate, and potential instability compared with HA.
Healy and Iorio examined the optimal treatment for elderly FNF. They compared internal fixation (120 patients) with arthroplasty (HA, 43 patients; THA, 23 patients). There was no different in reoperation or mortality rates between the 2 groups, but arthroplasty was more cost effective, had independent living, and longer interval to reoperation/death. THA had less pain, better function, and lower rates of reoperation than HA, and was most cost-effective. They concluded that THA was the best treatment.
Yu et al. performed a meta-analysis of randomized controlled trials to determine whether THA or hemiarthroplasty (HA) was superior. They found that THA had lower risk of reoperation (RR = 0.53), higher risk of dislocation (RR = 1.99), and
higher functional scores at 1 and 4 years. There was no difference in mortality, infection and complication rates.
Figure A shows a displaced left femoral neck fracture. Incorrect Answers:

Question 56

Duchenne’s muscular dystrophy is a genetic disorder that is transmitted by which of the following modes of inheritance?

Explanation

DISCUSSION: Patients with Duchenne’s muscular dystrophy show progressive muscular weakness because of the absence of dystrophin and have the clinical picture of progressive muscle weakness. The condition is an X-linked genetic disease.
REFERENCES: Fitzgerald RH, Kaufer H, Malkani AL: Orthopaedics. St Louis, MO, Mosby Year Book, 2002, pp 1573-1583.
Smith SA, Swaiman HF: Muscular dystrophies, in Swaiman KF, Ashwall S (eds): Pediatric Neurology Principles and Practice, ed 3. St Louis, MO, Mosby, 1999, pp 1235-1237.

Question 57

…A 56-year-old podiatrist with a negative past medical history had anterior knee pain after an injury. His radiographs, CT scan, and T1-weighted sagittal and fat-saturated axial MR images are shown in Figures 15a through 15e, respectively. After arthroscopic partial medial menisectomy, the patient was turned to the prone position and an open posterior arthrotomy and excision was performed. Low-power and high-power hematoxylin and eosin stained histologic specimens are shown in Figures 15f and 15g, respectively. Based on the history, radiographs, CT scan, MRI scans, and histologic findings, what is the most likely diagnosis?

Explanation

CLINICAL SITUATION FOR QUESTIONS 16 THROUGH 19
Figures 16a and 16b are the right femur radiographs of a 59-year-old man who has severe pain in his right distal thigh and knee with no significant trauma and an inability to bear weight. Blood tests demonstrate anemia, serum protein electrophoresis/urine protein electrophoresis findings are negative, and electrolyte levels are within defined limits.

Question 58

The insurance carrier of a patient who underwent total knee arthroplasty 4 days ago is now demanding that the patient be discharged from the hospital. However, examination reveals that the patient has a range of motion of only 10° to 55°, and the patient is concerned whether she will ever move her knee normally. The insurance company representative should be advised that

Explanation

DISCUSSION: Examination findings that show flexion of only 55° at discharge should alert the surgeon that the patient will require close scrutiny and follow-up. Mauerhan and associates examined the records of 745 patients who had a primary total knee arthroplasty from 1993 to 1996. At their institution, development and implementation of clinical pathways resulted in a significant decrease in the average length of stay, beginning in 1993 with 6.4 days +/- 1.8 days and progressively decreasing to 4.4 days +/- 1.0 days in 1996. The rate of manipulation (patients manipulated at 6 weeks/total number of patients receiving total knee arthroplasty) was 6.0% in 1993, 11.3% in 1994, 13.5% in 1995, and 12.0% in 1996. In the period of 1993 to 1996, patients requiring manipulation consistently had a lower range of motion of 69.0° +/- 10° at the time of discharge compared with patients not requiring manipulation who had a range of motion of 80.7° +/- 10.6°. In this era of outpatient services, however, another solution would be to arrange for outpatient physical therapy on a more frequent basis and to see the patient more frequently in the office until an acceptable range of motion is established.
REFERENCE: Mauerhan DR, Mokris JG, Ly A, Kiebzak GM: Relationship between length of stay and manipulation rate after total knee arthroplasty. J Arthroplasty 1998;13:896-900.

Question 59

What is the most common complication of halo vest immobilization in adults?

Explanation

DISCUSSION: Although pin loosening generally has not been considered a major problem, it has been cited as the most common complication in two published series of halo vest complications. The other possible complications are all significantly less common.
REFERENCES: Baum JA, Hanley EN Jr, Pullekines J: Comparison of halo complications in adults and children. Spine 1989;14:251-252.
Garfin SR, Botte MJ, Waters RL, Nickel VL: Complications in the use of the halo fixation device. J Bone Joint Surg Am 1986;68:320-325.
Nemeth JA, Mattingly LG: Six-pin halo fixation and the resulting prevalence of pin-site complications. J Bone Joint Surg Am 2001;83:377-382.

Question 60

A 67-year-old man who underwent humeral head arthroplasty for a four-part fracture 6 months ago reports that he is still unable to actively elevate his arm. Rehabilitation after surgery consisted of a sling with passive range-of-motion exercises for 2 weeks and then progressed to active-assisted and strengthening exercises at 3 weeks. Radiographs are shown in Figures 28a and 28b. What is the primary cause of his inability to elevate the arm?

Explanation

DISCUSSION: The radiographs show nonunion of both the greater and lesser tuberosities. Tuberosity pull-off and nonunion remain among the most common causes of failed humeral head arthroplasty for fracture. Strict attention to securing the tuberosities to each other and to the shaft, and autogenous bone grafting from the excised humeral head will decrease the incidence of pull-off and improve healing rates. Active-assisted range-of-motion and strengthening exercises should be delayed until tuberosity healing is noted radiographically, usually at 6 to 8 weeks postoperatively.
REFERENCES: Hartsock LA, Estes WJ, Murray CA, et al: Shoulder hemiarthroplasty for proximal humeral fractures. Orthop Clin North Am 1998;29:467-475.
Hughes M, Neer CS: Glenohumeral joint replacement and postoperative rehabilitation.

Phys Ther 1975;55:850-858.
Compito CA, Self EB, Bigliani LU: Arthroplasty and acute shoulder trauma. Clin Orthop 1994;307:27-36.

Question 61

-A 15-year-old boy with mild type I osteogenesis imperfecta (OI) has a midshaft radius/ulna fracture that is in bayonet apposition with loss of the radial bow and 40-degree apex volar and ulnar angulation. Closed reduction improves the angulation to 20 degrees; the bayonet apposition and loss of radial bow remains.His contralateral forearm has a normal appearance upon examination. What is the best treatment for this fracture?

Explanation

Question 62

An 18-month-old child sustains a crush amputation of the tip of the index finger. Bone is exposed, but the nail is intact. Management should consist of

Explanation

DISCUSSION: Children have a much greater capacity to heal soft-tissue injuries than adults. Most crush or avulsion fingertip amputations in children, particularly those younger than age 2 years, can be treated with serial dressing changes, even with bone exposed.
REFERENCES: Das SK, Brown HG: Management of lost finger tips in children.

Hand 1978;10:16-27.

Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg

1996;4:84-92.

Question 63

A 34-year-old male presents with elbow pain after sustaining a ground level fall 2 weeks ago. An injury radiograph is shown in Figure

Explanation

positive finding and is seen in valgus posterolateral rotatory instability of the elbow.

OrthoCash 2020

Question 64

A patient notes pain under the first metatarsophalangeal joint following a soccer injury. The MRI scans shown in Figures 27a and 27b reveal what pathologic finding?

Explanation

DISCUSSION: The MRI scans show a complete disruption of the sesamoid complex with proximal retraction of the medial sesamoid and high signal originating from the site normally occupied by the plantar plate (metatarsophalangeal ligament). This injury is the result of a hyperextension injury and is a severe variant of a turf toe.
REFERENCES: Watson TS, Anderson RB, Davis WH: Periarticular injuries to the hallux metatarsophalangeal joint in athletes. Foot Ankle Clin 2000;5:687-713.
Tewes DP, Fischer DA, Fritts HM, et al: MRI findings of acute turf toe: A case report and review of anatomy. Clin Orthop 1994;304:200-203.

Question 65

Examination of a hand with compartment syndrome is most likely to reveal which of the following?

Explanation

DISCUSSION: In a study of 19 patients with compartment syndrome of the hand, all had tense swollen hands with elevated compartment pressures. Most patients were neurologically compromised so pain with passive stretch may be difficult to illicit. Arterial inflow is present in the arch and thus pallor is not present. The typical posture of the hand is not clenched, rather it is an intrinsic minus posture of metacarpophalangeal joint extension and flexion of the proximal and distal interphalangeal joints.
REFERENCES: Oullette EA, Kelly R: Compartment syndromes of the hand. J Bone Joint Surg Am 1996;78:1515-1522.
Dellaero DT, Levin LS: Compartment syndrome of the hand: Etiology, diagnosis, and treatment. Am J Orthop 1996;25:404-408.

Question 66

An 8-year-old girl sustained a displaced fracture at the base of the femoral neck in a motor vehicle accident. Management should consist of

Explanation

DISCUSSION: Pediatric intracapsular hip fractures are challenging because of the high rates of complications, including osteonecrosis and varus malunion. These patients should be treated as emergencies. Principles of treatment include anatomic reduction with internal fixation. Screw fixation short of the physis is preferred and may need to be supplemented with spica cast immobilization. Fixation may be achieved with smooth pins across the physis when little metaphyseal bone is available. Fixation across the physis with threaded screws is acceptable only when the patient is close to skeletal maturity. Pediatric hip screws are appropriate if immediately available. Emergent open reduction, capsulotomy, or joint aspiration may decrease the rate of osteonecrosis.
REFERENCES: Cheng JC, Tang N: Decompression and stable internal fixation of femoral neck fractures in children can affect the outcome. J Pediatr Orthop 1999;19:338-343.
Azouz EM, Karamitsos C, Reed MH, et al: Types and complications of femoral neck fractures in children. Pediatr Radiol 1993;23:415-420.
Song KS, Kim YS, Sohn SW, et al: Arthrotomy and open reduction of the displaced fracture of the femoral neck in children. J Pediatr Orthop B 2001;10:205-210.
Morsy HA: Complications of fracture of the neck of the femur in children: A long-term follow-up study. Injury 2001;32:45-51.

Question 67

What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window?

Explanation

DISCUSSION: Care must be taken when placing a retractor on the anterior aspect of the sacrum, as the L4 and L5 nerve roots are both at risk. The first referenced article by Atlihan et al reported on the anatomy of the anterior sacroiliac joint and reported that the L4 nerve root is within 1 cm of the joint at its inferior margin. The second article by Ebraheim et al found that the L4 and L5 nerve roots are 10 mm medial to the sacroiliac joint at the pelvic brim

Question 68

Which of the following ligaments is the primary static restraint against inferior translation of the arm when the shoulder is in 0 degrees of abduction?

Explanation

DISCUSSION: The superior glenohumeral ligament (SGHL) and coracohumeral ligament serve as primary static restraints against inferior translation of the arm when the shoulder is in 0 degrees of abduction. Of these, the coracohumeral ligament has been shown to have a greater cross-sectional area, greater stiffness, and greater ultimate load than the SGHL. The inferior glenohumeral ligament plays a greater stabilizing role with increasing abduction of the arm. The coracoacromial ligament may help provide superior stability, especially when the rotator cuff is deficient. The coracoclavicular ligaments stabilize the acromioclavicular joint.
REFERENCES: Boardman ND, Debski RE, Warner JJ, et al: Tensile properties of the superior glenohumeral and coracohumeral ligaments. J Shoulder Elbow Surg 1996;5:249-254.
Warner JJ, Deng XH, Warren RF, Torzilli PA: Static capsuloligamentous restraints to superior-inferior translation of the glenohumeral joint. Am J Sports Med 1992;20:675-685.

Question 69

A 28-year-old male sustains a fall on icy ground and fractures his ankle. An intraoperative fluoroscopy image is shown in Figure A. This fixation suggests that the mechanism of injury was one of

Explanation

Moore I
Moore II
Schatzker III
Schatzker V
OTA type 41B3
Figure A shows a Moore Type II fracture. Moore type II fractures consist of fractures involving the entire tibial condyle, where the fracture line begins in the opposite compartment and extends across the tibial eminence.
A number of classification systems are used to describe tibial plateau fractures. The main classification systems that are widely used include Schatzker, AO/OTA, Hohl and Moore. The Moore classification describes high energy fracture-subluxation injuries of the knee. This is thought to have clinical implications as the type of fracture pattern can indicate an associated soft-tissue injury.
Moore retrospectively reviewed over a 1000 proximal tibia fractures to devise a classification systems based on the characteristic of five types of tibia plateau fracture patterns. He believed this system helped to better understand knee instability and concomitant soft-tissue injury. For example, Moore Type III fractures (rim avulsion) are associated with a high rate of neurovascular injury.
Figure A shows a fracture involving the entire tibial condyle. Illustration A shows a schematic diagram of the Moore classification (I - V). Illustration B shows a table that
describes the Moore classification (I - V).
Incorrect Answers:

Question 70

Radial nerve palsy is most commonly associated with which of the following types of humeral fractures?

Explanation

DISCUSSION: Although the Holstein-Lewis fracture, described as an oblique distal one third fracture, is best known for its association with neurologic injury, radial nerve palsy is most commonly associated with middle one third humeral fractures. Most nerve injuries are neurapraxias or axonotmeses, with up to 90% resolving in 3 to 4 months.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 271-286.
Pollock FH, Drake D, Bovill EG, Day L, Trafton PG: Treatment of radial neuropathy associated with fractures of the humerus. J Bone Joint Surg Am 1981;63:239-243.

Question 71

A healthy 27 year-old-male is brought into the emergency department after a fall from height. He has a suspected left C8-T1 nerve injury. Which of the following findings would most suggest a root avulsion injury rather than a brachial plexus injury at this level?

Explanation

Drooping of the left eyelid is a presenting feature of Horner's syndrome. Horner's syndrome represents a disruption of the sympathetic chain via C8 and/or T1 root avulsion after trauma.
Brachial plexus injuries are often classified as preganglionic vs. postganglionic injuries. Preganglionic injuries are typically avulsion injuries proximal to the dorsal root ganglion. Clinical features suggestive of lower root avulsion injury include a person falling from height clutching on object to save himself, Horner’s syndrome (drooping of the eyelid (ptosis), pupillary constriction (miosis) and anhidrosis), absence of a Tinel sign or tenderness to percussion in the neck, and a normal histamine test (C8-T1 sympathetic ganglion - intact triple response (redness, wheal, flare)).
Caporrino et al. reviewed 102 patients to assess the best modality (e.g. physical examination, MRI and nerve conduction studies [NCSs]) for diagnosing and localizing brachial plexus injuries. They found the best diagnostic performance with physical examination (sensitivity = 97.8%; specificity = 30.8%) and NCSs (sensitivity
= 98.9%; specificity = 23.1%). MRI had inferior performance for all measurements. They conclude that NCSs exhibited superior performance to MRI, and should be considered a more reliable supporting tool after detailed physical examination.
Incorrect Answers:

Question 72

A 62-year-old man who underwent total knee arthroplasty 6 months ago now reports pain after falling on the anterior portion of the knee. Examination reveals weakness of knee extension but no extensor lag. Flexion that had once measured 115 degrees is now limited to 70 degrees because of pain. A radiograph is shown in Figure 25. Management should now consist of

Explanation

DISCUSSION: The patient has a type IIIB patellar fracture (inferior pole fracture with an intact patellar tendon). Nonsurgical management is the treatment of choice if there is little displacement and the extensor mechanism is intact.
REFERENCES: Brown TE, Diduch DR: Fractures of the patella, in Insall JN, Scott WN (eds): Surgery of the Knee, ed 3. Philadelphia, PA, Churchill Livingstone, 2001, vol 2, pp 1290-1312.
Pellicci PM, Tria AJ Jr, Garvin KL (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2000,

pp 323-337.

Question 73

An 18-year-old football player is injured after making a tackle with his left shoulder. He has decreased sensation over the lateral aspect of the left shoulder and radial aspect of the forearm. Motor examination reveals weakness to shoulder abduction and external rotation as well as elbow flexion. He has decreased reflexes of the biceps tendon on the left side but full, nontender range of motion of the cervical spine. What anatomic site has been injured? Review Topic

Explanation

The athlete has symptoms referable to the axillary, musculocutaneous, and suprascapular nerves resulting from an injury to the upper trunk of the brachial plexus. This portion of the plexus is formed by contributions of the fourth through sixth cervical nerve roots. This area is often contused or stretched following a tackling maneuver that results in either depression of the shoulder from contact at Erb’s point or traction of the upper plexus from forced stretching of the neck to the contralateral side.

Question 74

On an axial CT image, which of the following dimensions is considered to be indicative of a critical amount of lumbar spinal stenosis? Review Topic

Explanation

Lumbar central stenosis is defined by an AP canal diameter of less than 10 mm or a cross-sectional area of less than 100 mm2 as measured on CT.

Question 75

Which of the following is a contraindication to laminoplasty in a patient with cervical spondylotic myelopathy?

Explanation

DISCUSSION: Laminoplasty or any posterior decompressive procedure is contraindicated in patients with cervical spondylotic myelopathy and cervical kyphosis. The residual kyphotic posture of the cervical spine results in persistent spinal cord compression. The other choices are not contraindications for laminoplasty. Concomitant cervical radiculopathy can be addressed at the time of laminoplasty with a keyhole foraminotomy.
REFERENCES: Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-247.

Question 76

An otherwise healthy 25-year-old man sustained a wound with a 1-cm by 1.5-cm soft-tissue loss over the volar aspect of the middle phalanx of his middle finger. After appropriate debridement and irrigation, the flexor digitorum profundus tendon and neurovascular bundles are visible. The wound should be treated with a

Explanation

DISCUSSION: The wound described indicates loss of soft tissue directly to the level of the tendon, precluding use of skin grafts if excursion of the tendon is desired. A cross-finger

flap is ideal for small wounds on the volar aspect of digits. A thenar flap is suitable for tip injuries. A lateral arm flap will not reach the fingers. A Moberg flap is limited to distal injuries of the thumb.
REFERENCES: Kappel DA, Burech JG: The cross-finger flap: An established reconstructive procedure. Hand Clin 1985;1:677-683.
Lister GD: Skin flaps, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1741.

Question 77

Figure 131 is the abdominal radiograph of a 70-year-old man who experiences nausea and abdominal tightness 48 hours after undergoing left total knee arthroplasty. An examination reveals severe abdominal distension and markedly decreased bowel sounds. Insertion of a nasogastric tube does not relieve abdominal tightness. What is the best next step?

Explanation

DISCUSSION
The abdominal radiograph reveals an acute colonic pseudo-obstruction. It is associated with parenteral narcotic use and hypokalemia. Initial treatment is insertion of a nasograstric tube, discontinuation of parenteral narcotics, and correction of electrolyte imbalances. If a pseudo-obstruction is not relieved, colonoscopy should be performed.

Question 78

A high school athlete reports the sudden onset of low back pain while performing a dead lift. Examination reveals lumbar paraspinal spasm and a positive straight leg raising test. Deep tendon reflexes, motor strength, and sensation in the lower extremities are normal. Radiographic findings are normal. If symptoms persist for longer than a few weeks, what is the best course of action?

Explanation

DISCUSSION: In the adolescent population, a lumbar herniated disk is characterized by a paucity of clinical findings, with a positive straight leg raising test the only consistently positive finding. This may result in a prolonged period of nonsurgical management that fails to provide relief. Activities that place a significant shear load on the lumbar spine, such as the dead lift, are associated with an increased risk of central disk herniation. An adolescent who lifts weights and has a history of back pain that fails to respond to a short period of active rest should undergo MRI evaluation for the diagnosis of a lumber herniated disk.
REFERENCES: Epstein JA, Epstein NE, Marc J, et al: Lumbar intervertebral disk herniation in teenage children: Recognition and management of associated anomalies. Spine 1984;9:427-432.
Hashimoto K, Fujita K, et al: Lumbar disc herniation in children. J Pediatr Orthop

1990;10:394-396.

Question 79

Figures 5a and 5b show the radiograph and MRI scan of a patient who has severe mechanical neck pain but no neurologic problems. Biopsy and work-up show the lesion to be a solitary plasmacytoma. Treatment should consist of

Explanation

DISCUSSION: Plasmacytoma is very sensitive to radiation therapy and given the complexity of the resection and complications of surgery in the given location, radiation therapy is preferred. However, the patient has clear loss of bony structural integrity, and resultant instability would persist even with tumor irradiation; therefore, posterior stabilization is warranted. Chemotherapy and bone marrow transplant are reserved for systemic disease with multiple myeloma.
REFERENCES: Corwin J, Lindberg RD: Solitary plasmacytoma of bone vs. extramedullary plasmacytoma and their relationship to multiple myeloma. Cancer 1979;43:1007-1013.
Durr HR, Wegener B, Krodel A, et al: Multiple myeloma: Surgery of the spine. Retrospective analysis of 27 patients. Spine 2002;27:320-324.

Question 80

Figure 25 shows the radiograph of an 84-year-old woman who has pain and is unable to extend her knee. History reveals that she underwent total knee arthroplasty 8 years ago. Aspiration and studies for infection are negative. During revision surgery, management of the tibial bone loss should consist of

Explanation

DISCUSSION: Massive bone loss encountered in revision total knee arthroplasty remains a significant challenge. Recent reports have shown high success rates using structural allograft to reconstruct large structural bone defects. A hinged prosthesis is not required in this setting. In this patient, a large amount of posterior cortex has been lost, making the area too large to fill with cement or iliac crest bone graft. Because of her age, the treatment of choice is a revision tibial implant and metal augments. Structural allograft would be suitable in a younger patient.
REFERENCES: Mow CS, Wiedel JD: Structural allografting in revision total knee arthroplasty. J Arthroplasty 1996;11:235-241.
Engh GA, Herzwurm PJ, Parks NL: Treatment of major defects of bone with bulk allografts and stemmed components during total knee arthroplasty. J Bone Joint Surg Am 1997;79:1030-1039.
Clatworthy MG, Ballance J, Brick GW, et al: The use of structural allograft for uncontained defects in revision total knee arthroplasty: A minimum five-year review. J Bone Joint Surg Am 2001;83:404-411.

Question 81

A 9-year-old boy falls from a scooter and sustains the injury shown in the radiographs in Figure 26. After closed reduction and cast immobilization, what is the most likely complication that can result?

Explanation

DISCUSSION: The radiographs show a fracture of the distal radius and ulna physis. The most likely complication is growth arrest of the distal ulna. In contradistinction to physis fractures of the radius (growth arrest incidence of less than 5%), the incidence of growth arrest in the ulna is between 30% and 40%. Entrapment of the EPL tendon and cross union between the two bones is extremely rare.
REFERENCES: Vanheest A: Wrist deformities after fracture. Hand Clin 2006;22:113-120.
Cannata G, De Maio F, Mancini F, et al: Physeal fractures of the distal radius and ulna: Long-term prognosis. J Orthop Trauma 2003;17:172-179.
Ray TD, Tessler RH, Dell PC: Traumatic ulnar physeal arrest after distal forearm fractures in children. J Pediatr Orthop 1996;16:195-200.
Aminian A, Schoenecker PL: Premature closure of the distal radial physis after fracture of the distal radial metaphysis. J Pediatr Orthop 1995;15:495-498.

Question 82

What is the most common location for localized pigmented villonodular synovitis (PVNS) to occur?

Explanation

DISCUSSION: Localized PVNS is a form of the disease in which synovial proliferation is restricted to one area of a joint and causes the formation of a small mass-like lesion. The true incidence of this is unknown but is probably less common than the diffuse form of the disease. PVNS presents as a usually painful discrete mass. The anterior compartment of the knee is the most common location.
REFERENCES: Tyler WK, Vidal AF, Williams RJ, et al: Pigmented villonodular synovitis.

J Am Acad Orthop Surg 2006;14:376-385.
Kim SJ, Shin SJ, Choi NH, et al: Arthroscopic treatment for localized pigmented villonodular synovitis of the knee. Clin Orthop Relat Res 2000;379:224-230.

Question 83

A 17-year-old high school gymnast who has peripatellar knee pain has been unable to practice on a consistent basis for the past 3 years. She denies any specific injury events. Physical therapy for modalities, quadriceps strengthening, and hamstring stretching provide temporary relief. A trial of patellar taping significantly reduces her pain. Examination reveals an 15-degree Q angle, moderate lateral facet tenderness, negative patellar apprehension, and the inability to evert the patella. Radiographs show a moderate lateral patellar tilt. Treatment should now consist of

Explanation

DISCUSSION: The patient has patellofemoral stress and a tight lateral retinaculum that has failed to respond to nonsurgical management; therefore, the most appropriate treatment includes an arthroscopic lateral retinacular release. A patellar restraining brace may aggravate the peripatellar pain by increasing pressure on the lateral facet. There is no evidence of patellar instability or significant malalignment; therefore, medial retinacular repair or a tibial tubercle transfer is not indicated. A modified Maquet tibial tubercle elevation would be considered only for significant patellofemoral arthrosis.
REFERENCES: Gambardella RA: Techical pitfalls of patellofemoral surgery. Clin Sports Med 1999;18:897-903.
Post WR: Clinical evaluation of patients with patellofemoral disorders. Arthroscopy 1999;15:841-851.

Question 84

If a percutaneous iliosacral screw is placed too anteriorly, and the screw exits anterior to the sacral ala before re-entering the sacral body, what will be the most likely finding postoperatively?

Explanation

DISCUSSION: This question is a simple review of anatomy and nerve innervation. The L5 root is at risk with an "in-out-in" screw, as described in the question, as the nerve root is just anterior to the sacral ala as it enters the true pelvis. L5 is primarily evaluated by extensor hallucis longus function. L4 is tested with tibialis anterior function and S1 by gastroc-soleus function (ankle plantarflexion).

Question 85

A 52-year-old man has pain in the sternal area after landing on his right shoulder in a fall from his bicycle. In addition, he reports that he had difficulty swallowing and breathing immediately after the fall, but the symptoms resolved. A CT scan reveals a posterior sternoclavicular dislocation. Initial management should include

Explanation

DISCUSSION: Posterior sternoclavicular dislocations require rapid treatment because of the proximity of major neurovascular structures and the airway. Initial management should consist of closed reduction under general anesthesia in the operating room with a chest surgeon available. A successful closed reduction is usually stable. Internal fixation of sternoclavicular injuries should be avoided because of the likelihood of hardware migration and possible injury to the mediastinal structures. If closed reduction is unsuccessful, open reduction is indicated. Treatment following reduction of the sternoclavicular joint includes the application of a figure-of-8 splint and a sling for 6 weeks, followed by stretching and strengthening exercises.
REFERENCES: Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont IL, American Academy of Orthopaedic Surgeons, 1999, pp 287-297.
Rockwood CA Jr: Disorders of the sternoclavicular joint, in Rockwood CA Jr, Matsen FA III (eds): The Shoulder. Philadelphia, PA, WB Saunders, 1990, vol 2, pp 1010-1017.

Question 86

When performing a revision total knee arthroplasty, trial components are inserted and the knee is stable in extension and loose in flexion. Which step should be taken to create a stable construct?

Explanation

DISCUSSION
The surgeon is facing a common scenario that occurs in revision knee surgery: a loose flexion gap with an appropriate extension gap. A flexion gap can be tightened by translating the femoral component more posteriorly and using an oversized femoral component. Insertion of a thicker tibial component changes both the flexion and extension gap. Augmentation of the distal femur tightens only the extension gap. A constrained insert would only be indicated if oversizing of the femoral component did not adequately tension the flexion gap.

Question 87

When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?

Explanation

DISCUSSION: As the chance of success of lumbosacral fusion increases with the stiffness and rigidity of the construct, fixation and stiffness improve with fixation into both the upper sacrum and the ilium. In a review of individuals treated with long constructs to the pelvis for adult scoliosis, Islam and associates reported that the rate of pseudarthrosis was significantly lower with sacral and iliac fixation compared with sacral fixation alone or iliac fixation alone. Iliac screws provide significant fixation anterior to the instantaneous axis of rotation for flexion and extension, as well as provides resistance to lateral bending and rotational forces. Numerous biomechanical studies support the concept of increasing biomechanical stabilization with increased fixation from the sacrum to the ilium.
REFERENCES: Islam NC, Wood KB, Transfeldt EE, et al: Extension of fusions to the pelvis in idiopathic scoliosis. Spine 2001;26:166-173.
O’Brien N, et al: Sacral pelvic fixation and spinal deformity, in DeWald RL (ed): Spinal Deformities: A Comprehensive Text. New York, NY, Thieme, 2003, pp 601-614.
McCord DH, Cunningham BW, Shono Y, et al: Biomechanical analysis of lumbosacral fixation. Spine 1992;17:S235-S243.

Question 88

Figure 1 is the MRI scan of a 35-year-old female soccer player who injured her knee during a game. Given the findings of the scan, physical examination is most likely to reveal

Explanation

The MRI scan clearly reveals bone bruises in the mid lateral femoral condyle and posterior tibial plateau. These MRI findings are commonly associated with acute anterior cruciate ligament injuries. Therefore, the preferred answer would be a positive pivot shift examination. A positive posterior drawer and positive quad active test are associated with posterior cruciate ligament injuries. A positive dial test would be suggestive of a posterolateral instability of the knee.

Question 89

03 A patient with carpometacarpal joint arthritis of the thumb undergoes trapezium excision and interposition arthroplasty. One year after treatment, radiographs reveal that there has been 25% subsidence of the thumb metacarpal compared with its preoperative height. This degree of subsidence will have what effect on the surgical outcome?

Explanation

Yang and Weiland, from New York studied subsidence after trapezium excision and interposition arthroplasty. They compared preoperative and postoperative x-rays at rest as well as with maximal lateral key pinch stress. Lateral key
pinch stress causes a large amount of axial compressive force through the CMC joint. They also compared preoperative and postoperative functional measurements, including key pinch strength, tipto-tip pinch strength, grip strength, and thumb ROM. Their findings were that postoperatively the first metacarpal subsided 21% at rest (p=0.001). and it subsided another 10.5% during maximal lateral key pinch. Even with this degree of subsidence, the patients experienced increases in pinch strength and grip strength. Also, all patients except for one who had bony impingement reported that they were subjectively much better and more functional.
Lin et. al. also studied trapezium excision and interposition arthroplasty and found no significant differences between results in patients with varying degrees of subsidence. Thus, subsidence does not affect the results of interposition arthroplasty for basal thumb arthritis.
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Question 90

What do the T2-weighted, fat-saturated MRI scans shown in Figures 1 through 4 reveal?

Explanation

The MRI scans show that edema is noted on the femoral insertion of the ACL consistent with a high-grade or complete ACL tear. The ACL is not visualized on the sagittal view, although the torn meniscus can be seen in the notch. On the coronal image, there is an empty lateral wall sign indicating proximal
disruption of the ACL. The medial meniscus images show a disruption of normal meniscus morphology consistent with a bucket handle medial meniscus tear. Note the appearance on the sagittal MRI scan of what appears to be a second soft-tissue density in line with the PCL. This "double PCL" sign is highly indicative of a displaced medial meniscus tear rather than a displaced lateral meniscus tear.

Question 91

Examination of a 45 year old construction worker who was crushed by falling dirt and buried to midchest level reveals hemodynamic instability; however, radiographs of the chest are normal, and results of a diagnostic peritoneal lavage are negative. Despite the administration of a fluid bolus and packed red blood cells, hemodynamic instability persists. A radiograph of the pelvis is shown in Figure 4. The next step in the management should be

Explanation

In patients with pelvic fractures who are hemodynamic unstable upon presentation, the initial management starts with application of external pelvic fixation. If there is no response (stabilization of vital signs and decreased fluid requirements), pelvic angiography with possible embolization is the next course of treatment. Open reduction internal fixation can be performed following General surgical management of associated abdominal injuries. Pelvic fractures have a high association of retroperitoneal bleeding which may not be necessarily be picked up from diagnostic peritoneal lavage.

Question 92

below show the radiographs, MRI, and MR arthrogram obtained from a year-old collegiate soccer player who has new-onset left groin pain. He played competitive soccer from a young age and has competed or practiced 5 to 6 times per week since the age of He denies any specific hip injury that necessitated treatment, but his trainer contends that he had a groin pull. He reports groin pain with passive flexion and internal rotation of the left hip, and his hip has less internal rotation than his asymptomatic right hip. He is otherwise healthy. What is the primary cause of a cam deformity?

Explanation

Multiple studies have confirmed that cam or pincer anatomy is commonly present in asymptomatic hips. According to a large systematic review, cam deformities are present in approximately one-third of asymptomatic hips in young adults, and the proportion is higher than 50% in the subgroup of athletes. Ganz and associates proposed that femoral acetabular impingement is the root cause of osteoarthritis in most nontraumatic, nondysplastic hips, and functional improvement with surgical correction of the deformity has been demonstrated. Despite the link between cam deformity and hip osteoarthritis, a corresponding link between the correction of the deformity and prevention of osteoarthritis has never been proven. The results of cam deformity correction, typically including repair of the degenerative labral tear, are much poorer when substantial joint space loss is present. A typical joint space cutoff of 2 mm or less is used to recommend against hip preservation surgery.

Question 93

During head-on motor vehicle collisions occurring at highway speeds, airbag-protected individuals have a decreased rate (as compared to non-airbag protected individuals) of all of the following EXCEPT:

Explanation

DISCUSSION: The referenced study by Loo et al. studied the interaction between airbags/seatbelts and mechanism of the crash (ie. front vs. side impact) and the injury patterns in these patients. They found that in frontal crashes, airbags reduced Glasgow Coma Scale severity in brain injury, facial fracture, shock, thoracoabdominal injuries and the need for extrication. Frontal airbags also had a protective effect on lower extremity fractures, but had no significant protective effect on pelvic fractures.

Question 94

A 25-year-old patient who was wearing a seat belt in the back chair of a car involved in a head-on collision undergoes a laparotomy. During surgery, an injury to the sigmoid colon is identified and treated. Two days later the patient has back pain when sitting in a chair. What is the most likely diagnosis?

Explanation

Number four is correct because it fits the injury pattern and symptoms of the scenario given above. (Chance/Seat Belt Fracture) Number one is incorrect because it is the most “likely” diagnosis in this injury pattern. It would need more of a direct blow type of injury to be true. Number two is incorrect because it does not fit the injury pattern. The burst fracture is usually an axial/vertical loading injury. Number three is incorrect because the patient is having back pain only and no lower extremity or bowed/bladder complaints that you would typically find in a cauda equina syndrome. Number five is incorrect because it does not fit the injury pattern of the scenario given above with comparison to the number four answer.

Question 95

Two years ago, a 63-year-old man underwent right total hip arthroplasty (THA) with a modular femoral head-neck and neck-stem prosthesis (a photograph of the removed implant is shown in Figure 181). He now has increasing hip pain. Radiographs reveal a stable hip arthroplasty and elevated serum cobalt and chromium levels. MR imaging is obtained, and, based on these findings, the patient’s hip is revised. Which corrosion type likely is responsible for this THA failure?

Explanation

DISCUSSION
Micromotion at the femoral head-neck or stem-neck junction can lead to fretting corrosion. Fretting corrosion is among the most common causes of failure in modular components. Modularity gives surgeons additional intraoperative flexibility but has resulted in corrosion-related failure and an implant recall. Although titanium and cobalt-chrome contain a protective surface oxide layer, continued micromotion at the modular junction may disrupt the protective layer, resulting in fretting corrosion. This may eventually lead to excessive metal ion formation and painful synovitis that necessitates a revision procedure. Galvanic corrosion is attributable to a mismatch in electrochemical gradients between dissimilar metals. Crevice or pitting corrosion occurs in fatigue cracks because of differences in oxygen tension.

Question 96

A 14-year-old boy is involved in a motor vehicle accident and sustains the injury shown in Figures 18a and 18b. What is the most likely diagnosis? Review Topic

Explanation

Talar neck fractures are uncommon. In children younger than age 6 years, displacement is rare and closed treatment is usually successful in achieving union and avoiding osteonecrosis. In adolescence, however, talar neck fractures should be treated as they are in adults. This fracture is displaced, and there is dislocation of the subtalar joint. The tibiotalar and talonavicular joints remain reduced. In the classification originally created by Hawkins and modified by Canale and Kelly, this would be a Hawkins type II, carrying a 20% to 50% risk of osteonecrosis. The rate of osteonecrosis increases with the Hawkins grade. The presence of talar neck comminution and open talar neck fractures are also risk factors for osteonecrosis after talar neck fracture.

Question 97

Video 1 shows a 20-year-old right-hand dominant man with a 6-month history of left wrist pain and popping that has failed nonsurgical measures. No other positive findings upon examination are noted. What is the most appropriate course of treatment?

Explanation

A 53-year-old woman is experiencing thumb weakness. She has a remote history of a wrist fracture treated with a cast. She cannot lift her thumb off of a table when her hand is lying flat, palm-down. What is the most appropriate course of treatment?
A. Abductor pollicis longus reconstruction with palmaris autograft
B. Extensor pollicis brevis repair
C. Extensor pollicis longus (EPL) repair
D. Extensor indicis proprius (EIP) to extensor pollicis longus tendon transfer
The EPL is the only tendon that will lift a thumb off of a table as described. It is the most frequently ruptured tendon associated with distal radius fractures. Rupture is more common with nondisplaced fractures. Rupture after a nondisplaced or minimally displaced fracture suggests an ischemic etiology. The patient will not be able to lift her thumb off of a table with her hand lying flat, palm-down. Direct repair is often difficult because of retraction of tendon ends, atrophy, and fraying. The EIP has a similar amplitude and direction of pull. Prerequisites for the use of the EIP to EPL tendon transfer include independent extension of the index finger.
15- Figure 1 is the clinical photograph of a very functional 17-year-old boy with cerebral palsy and quadriplegia. He has no active supination but has full passive supination. His ability to determine position and sensibility without visual input are good. Radiographs show no osseous malalignment. Which treatment can best improve this patient's function?
A. Physical therapy for supination strengthening
1- Figures 1 through 3 are the radiographs of a 40-year-old woman who sustained a minor injury to her left ring finger. Prior to this injury she was asymptomatic, but she now notes pain and swelling. What is the best course of treatment?

A. Observation only
B. Fluoroscopic-guided intralesional steroid injection followed by serial radiographs
C. Immediate curettage without bone grafting
D. Splint immobilization with curettage and possible grafting after the fracture has healed
This patient has a fracture of the middle phalanx attributable to the presence of an enchondroma. Enchondromas are the most common benign bone tumor affecting the hand. This particular enchondroma has thinned the cortices extensively so that even minor trauma can cause a pathologic fracture. Observation is not the best treatment because a fracture is present, and, at a minimum, the digit should be immobilized.

Question 98

A 65-year-old woman fell onto her outstretched right arm and immediately had pain. She has a history of osteoporosis. Examination of the right arm reveals lateral arm swelling, ecchymosis, and she is unable to move the elbow due to pain. Her neurovascular status is intact. Radiographs are shown in Figures 14a and 14b. Appropriate treatment should include

Explanation

DISCUSSION: Comminuted, displaced radial head fractures (Hotchkiss type 3) require anatomic metallic radial head arthroplasty to regain function. Radial head excision has led to catastrophic sequelae including chronic wrist pain, elbow instability, and proximal radius migration. Immobilization, internal fixation, or anconeus arthroplasty are not recommended at this time because of the potentially poorer outcomes.
REFERENCES: Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.
Beredjiklian PK, Nalbantoglu U, Potter HG, et al: Prosthetic radial head components and proximal radial morphology: A mismatch. J Shoulder Elbow Surg 1999;8:471-475.

Question 99

A 24-year-old former high school wrestler had anterior cruciate ligament (ACL) reconstruction with hamstring autograft 6 years ago. He now experiences daily instability of his knee with routine activities including walking. Examination reveals a grade 3+ Lachman test with a soft endpoint, varus laxity at 30°, and a positive dial test at 30° that dissipates at 90° of knee flexion. He has mild medial joint line tenderness. When walking, there is a slight varus thrust. What treatment is most likely to lead to a successful outcome?

Explanation

This patient underwent an ACL reconstruction that has now failed. Based on his examination, he also has a posterolateral corner injury. Because this concomitant injury was not treated, the patient had undue strain on his graft, resulting in ultimate failure. Hamstring grafts are as effective as other graft types for ACL reconstruction. The medial meniscus provides secondary stabilization to the knee; however, this patient has a missed lateral ligamentous injury, and meniscus tears do not result in the development of a varus thrust. An unrecognized PCL tear likely results in mild-to-moderate medial and patellofemoral osteoarthritis without significant lateral laxity and thrust.

Question 100

Figure 49 shows an acute axial MRI scan of a right knee. What is the most likely diagnosis? Review Topic

Explanation

The MRI scan shows bone bruises in the medial aspect of the patella and the lateral aspect of the lateral femoral condyle. Both of these signs are typical for a lateral dislocation of the patella with spontaneous reduction. In addition, there may be associated tearing of the medial retinaculum or distal aspect of the vastus medialis.

Full Question & Answer Text (for Search Engines)

Question 1:

Options:

popliteal cyst.
posterior cruciate ligament tear.
torn and displaced posterior horn of the medial meniscus.
normal meniscofemoral ligament of Humphry.
normal meniscofemoral ligament of Wrisberg.

Correct Answer: torn and displaced posterior horn of the medial meniscus.

Explanation:

Question 2:

Options:

Clear cell sarcoma
Clear cell carcinoma
Epidermal inclusion cyst
Nora’s tumor (BPOP)
Epithelioid sarcoma

Correct Answer: Epithelioid sarcoma

Explanation:

DISCUSSION: Epithelioid sarcoma is the most common soft-tissue sarcoma in the hand and most commonly occurs in young adults. The tumors can be superficial and may become ulcerated. Deeper lesions are often attached to tendons, tendon sheaths, or fascial structures. These are usually minimally symptomatic. The biopsy specimen reveals the typical appearance of a nodular pattern with central necrosis. They can mimic a necrotizing granulomatous process. Usually there are chronic inflammatory cells along the margin of the tumor nodules. This biopsy specimen does not have the clear cells necessary for a clear cell carcinoma or sarcoma. Nora’s tumor is a bizarre parosteal osteochondromatous proliferation (BPOP) first described in 1983 by the pathologist, Nora. The lesion is defined as a reactive heterotopic ossification and is mostly found in the hands or feet of adults in the third decade of life.
REFERENCES: Enzinger FM, Weiss SW: Soft Tissue Tumors, ed 3. St Louis, MO, Mosby, 1995, p 1074.
Halling AC, Wollan PC, Pritchard DJ, et al: Epithelioid sarcoma: A clinicopathologic review of 55 cases. Mayo Clin Proc 1996;71:636-642.

Question 3:

Options:

Biopsy
Resection
A CT scan
An MRI scan
Observation

Correct Answer: Observation

Question 4:

During percutaneous iliosacral screw placement for an unstable pelvic ring injury, use of the lateral sacral fluoroscopic image is critical to help avoid iatrogenic injury to what structure?

Options:

L4 nerve root
L5 nerve root
S1 nerve root
Sacroiliac joint cartilage
External iliac artery

Correct Answer: L4 nerve root

Explanation:

Question 5:

Options:

cast immobilization.
delayed fixation of the medial malleolus.
immediate fixation of the medial malleolus and plating of the fibula.
immediate fixation of the medial malleolus, plating of the fibula, and placement of a syndesmotic screw.
immediate fixation of the medial malleolus and placement of a syndesmotic screw.

Correct Answer: immediate fixation of the medial malleolus, plating of the fibula, and placement of a syndesmotic screw.

Explanation:

Question 6:

A 24-year-old man is ejected from his motorcycle and sustains a significant hip injury. The fracture shown in Figures 64a through 64e is best described as what type of fracture?

Options:

Posterior column/posterior wall acetabular
Associated both column acetabular
Transverse plus posterior wall acetabular
Anterior column posterior hemitransverse acetabular
Anterior column acetabular

Correct Answer: Anterior column acetabular

Explanation:

DISCUSSION: The radiographs and CT scans reveal an anterior column acetabular fracture. The fracture has quadrilateral plate extension but does not exit out the posterior column. The CT scans confirm an intact posterior column and no wall fracture. A transverse fracture is best seen on the CT scan and runs in the sagittal plane, not the coronal plane.
REFERENCES: Letournel E, Judet R: Fractures of the Acetabulum, ed 2. New York, NY, Springer-Verlag, 1993, pp 115-140.
Beaule PE, Dorey FJ, Matta JM: Letournel classification of acetabular fractures: Assessment of interobserver and intraobserver reliability. J Bone Joint Surg Am 2003;85:1704-1709.

Question 7:

- Which of the following provides the most stable fixation for comminuted fractures of the posterior acetabular wall?

Options:

Cable
Buttress plate
Methylmethacrylate
Multiple lag screws
Multiple Kirschner wires

Correct Answer: Buttress plate

Explanation:

Question 8:

Options:

Anterior shoulder dislocation
Humeral component loosening
Glenoid component loosening
Glenoid component catastrophic fracture
Rotator cuff tear

Correct Answer: Rotator cuff tear

Explanation:

DISCUSSION: The patient has a traumatic rotator cuff tear. The history of the fall, the weakness on examination, and normal radiographic findings make a traumatic rotator cuff tear the most likely diagnosis. An MRI scan can be obtained to further evaluate the integrity of the rotator cuff. The axillary radiograph shows a reduced, nondislocated total shoulder arthroplasty. His radiographs show a well-seated humeral stem and no signs of loosening. The glenoid is a cemented all-polyethylene component with no evidence of radiolucent lines surrounding the cemented pegs. The polyethylene glenoid component is radiolucent; however, the space between the metallic humeral head and the glenoid bone is the thickness of the polyethylene glenoid component. If the humeral head were directly against the glenoid bone, then catastrophic fracture of the glenoid would be the working diagnosis.
REFERENCES: Hattrup SJ, Cofield RH, Cha SS: Rotator cuff repair after shoulder replacement. J Shoulder Elbow Surg 2006;15:78-83.
Sperling JW, Potter HG, Craig EV, et al: Magnetic resonance imaging of painful shoulder arthroplasty. J Shoulder Elbow Surg 2002;11:315-321.

Question 9:

Thoracic disk herniations most typically occur at what level of the thoracic spine? Review Topic

Options:

Upper third
Junction of upper third and middle third
Middle third
Junction of middle third and lower third
Lower third

Correct Answer: Lower third

Explanation:

Question 10:

Options:

ixation of the coronoid fragment
Radial head arthroplasty
Repair or reconstruction of the lateral collateral ligament (LCL) complex
Repair or reconstruction of the medial collateral ligament (MCL) This represents a terrible triad injury, with elbow dislocation, radial head fracture, and coronoid fracture. The LCL complex is typically disrupted in this injury pattern. Repair or reconstruction of this structure provides the greatest increase in rotational stability of the elbow.

Correct Answer: Repair or reconstruction of the lateral collateral ligament (LCL) complex

Explanation:

A 68-year-old right-hand dominant woman has experienced progressive right elbow pain and loss of motion for several years. She has failed nonsurgical treatment and elects to undergo a total elbow arthroplasty (TEA). In comparison to a linked prosthesis, an unlinked prosthesis has which reported distinction with extended follow-up?
A. Improved longevity in comparison to the linked prosthesis
B. A significantly larger flexion-extension arc
C. A higher incidence of postsurgical instability
D. Lower frequency of ulnar nerve dysfunction
TEA is a popular option for treatment of end-stage elbow arthritis for elderly, lower-demand patients with rheumatoid arthritis. Good success rates have been published by several authors. The clear benefit of the current nonconstrained prosthesis has yet to be proven. Plaschke and associates investigated the Danish National Patient Registry to compare the longevity of the 2 types of implants. These authors found similar survival rates associated with both linked and unlinked implants at 10 years (88% and 77%, respectively). However, studies have documented an approximate 20% incidence of postsurgical instability with nonconstrained implants.

Question 11:

Options:

an oral cephalosporin antibiotic and discharge home.
IV oxacillin and gentamicin.
arthroscopic drainage of the glenohumeral joint.
open irrigation and drainage of the glenohumeral joint.
aspiration of the glenohumeral joint and subacromial space with Gram stain and culture of the fluid.

Correct Answer: aspiration of the glenohumeral joint and subacromial space with Gram stain and culture of the fluid.

Explanation:

Question 12:

Options:

Ascending branch of the lateral femoral circumflex
Superior gluteal
Femoral
Profunda femoris
Medial femoral circumflex

Correct Answer: Ascending branch of the lateral femoral circumflex

Explanation:

DISCUSSION: The ascending branch of the lateral femoral circumflex artery crosses the gap between the tensor fascia lata and the sartorious and must be identified and ligated or coagulated. The other vessels are out of the field of dissection.
REFERENCES: Barrack RL, Booth RE Jr, Lonner JH, et al (eds): Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, p 312.
Hoppenfeld S, deBoer P: Surgical Exposures in Orthopaedics: The Anatomic Approach. Philadelphia, PA, JB Lippincott, 1984, p 304.

Question 13:

Options:

No change in paresthesias and grip strength
Increase in grip strength and decrease in paresthesias
Decrease in grip strength and increase in paresthesias
Increase in grip strength and paresthesias

Correct Answer: Increase in grip strength and decrease in paresthesias

Explanation:

Question 14:

Options:

Transtibial amputation
Transmetatarsal amputation
Wide resection and radiation therapy
Ray resection and radiation therapy
Transfemoral amputation

Correct Answer: Transtibial amputation

Explanation:

DISCUSSION: Certain histologic subtypes of soft-tissue sarcoma have been noted to arise preferentially in the hand and the foot, such as epithelioid sarcoma, clear cell sarcoma, and synovial sarcoma. Synovial sarcoma is the most common foot sarcoma. Frequently there is a delay in diagnosis because the lesions are rare. The lesions tend to occur in younger adults, typically between the ages of 15 and 40 years. Patients with hand and foot sarcomas have been described as having improved overall survival, but this is likely a result of the smaller size of tumors arising in these locations. In this patient, the tumor has grown to a substantial size and involves many of the bones of the midfoot. Limb salvage may be a possibility when incorporated into a multidisciplinary treatment program, but this will entail months of adjuvant treatment and significant morbidity. Amputation and early prosthetic fitting still have a role in management of some soft-tissue sarcomas, most frequently in the foot.
REFERENCES: Ferguson PC: Surgical considerations for management of distal extremity soft tissue sarcomas. Curr Opin Oncol 2005;17:366-369.
Scully SP, Temple HT, Harrelson JM: Synovial sarcoma of the foot and ankle. Clin Orthop Relat Res 1999;364:220-226.

Question 15:

Immobilization with a sling

Options:

Aspiration and steroid injection
Biopsy, curettage, and allograft bone grafting
Percutaneous Kirschner wire fixation
Percutaneous injection of autogenous bone marrow

Correct Answer: Aspiration and steroid injection

Explanation:

Question 16:

Options:

Inadequate physical therapy
Exposure of the periosteum of the lateral ulna during surgery
Inappropriate location of the suture anchor
Fixation of the tendon with the forearm fully pronated
Subluxation of the radial head

Correct Answer: Exposure of the periosteum of the lateral ulna during surgery

Explanation:

Question 17:

The iliopectineal fascia runs between which of the following structures?

Options:

Iliopsoas muscle and the iliac vessels/femoral nerve
Lateral femoral cutaneous nerve and the iliac vessels
Iliopsoas muscle/femoral nerve and the iliac vessels
Iliac wing and the iliopsoas muscle
Pubic symphysis and the iliac vessels

Correct Answer: Iliopsoas muscle/femoral nerve and the iliac vessels

Explanation:

DISCUSSION: The sheath of the psoas muscle or the iliopectineal fascia separates the more lateral iliopsoas muscle and the femoral nerve from the more medially located iliac vessels. This fascia has to be taken down to enter the true pelvis.
REFERENCES: Masquelet AC, McCullough CJ, Tubiana R: An Atlas of Surgical Exposures of the Lower Extremity. Philadelphia, PA, JB Lippincott, 1993.
Letournel E, Judet R: Fractures of the Acetabulum, ed 2. Berlin, Germany, Springer Verlag, 1993.
Matta J: Surgical treatment of acetabular fractures, in Browner BD, Jupiter JB, Levine AM, et al (eds): Skeletal Trauma, ed 3. Philadelphia, PA, WB Saunders, 2003, vol 1, pp 1109-1149.

Question 18:

Options:

Kaposi sarcoma
Squamous cell carcinoma
Pigmented basal cell carcinoma
Melanoma
Basillary angiomatosis

Correct Answer: Melanoma

Explanation:

Question 19:

Options:

Nerve conduction velocity studies and electromyography
Extension splinting of the fingers
Exploration and repair of the extensor tendon laceration
Exploration and repair of the posterior interosseous nerve
Observation

Correct Answer: Exploration and repair of the posterior interosseous nerve

Explanation:

Question 20:

Options:

Before fasciotomy closure
At fasciotomy closure
After fasciotomy closure
After 24 hours of antibiotic treatment
Timing of definitive fixation does not alter infection risk Corrent answer: 5 The timing of definitive fixation of tibial plateau fractures in patients with fasciotomies has no impact on infection risk. The incidence of compartment syndrome is high in tibial plateau fractures. In the presence of tense anterior and lateral tibial compartments, combined with pain with passive stretch of involved muscles or unrelenting pain, compartment pressures should be measured and fasciotomies performed when necessary. Schatzker type V and VI fractures are more likely to have this potential complication. Examination of leg compartments should be repeated at regular intervals because compartment syndrome may occur 24 hours or more after injury. Zura et al. performed a study to analyze whether there is an association between infection and the timing of definitive fracture fixation in relation to fasciotomy closure or coverage. They found that no statistical difference in the rate of infection when tibial plateau fractures with four-compartment fasciotomies were treated with open reduction and internal fixation before fasciotomy closure, at fasciotomy closure, or after fasciotomy closure. They conclude that timing of definitive fracture treatment can be determined by the medical condition of the patient. Shah et al. performed a retrospective chart review of all bicondylar tibial plateau fractures that had fixation with two incisions. They reported an infection rate of 13.8% which is lower than historical reports. They concluded that the lower infection rate was due to their treatment algorithm that requires recovery of the soft tissue envelope prior to definitive fixation. Figure A demonstrates a bicondylar tibial plateau fracture. Figure B demonstrates fixation of a tibial plateau fracture through a dual plating technique. Incorrect Answers:

Correct Answer: Before fasciotomy closure

Explanation:

OrthoCash 2020

Question 21:

Options:

Positive froment sign with the ulnar palm flat on a table
Weak thumb abduction with the dorsal palm flat on a table
Inability to flex the thumb with the palm flat on a table
Inability to extend the thumb with the palm flat on a table

Correct Answer: Inability to extend the thumb with the palm flat on a table

Explanation:

Question 22:

-What gene is implicated in spinal muscular atrophy?

Options:

Survival motor neuron I (SMN-I)
Peripheral myelin protein 22 (PMP22)
Dystrophin
Androgen receptor DISCUSSION-Deletions in the SMN-I gene are found in 95% to 98% of patients with spinal muscular atrophy. Genetic testing is typically part of the diagnostic workup for spinal muscular atrophy. A positive test result is diagnostic, and, in most cases, eliminates the need for muscle biopsy. The other choices are not associated with spinal muscular atrophy. Defects in PMP22 are the cause of 70% to 80% of cases of Charcot-Marie-Tooth disease. Mutations in the dystrophin gene cause Duchenne muscular dystrophy, and mutations in the androgen receptor cause spinobulbar muscular atrophy (Kennedy’s disease).

Correct Answer: Survival motor neuron I (SMN-I)

Question 23:

Options:

MRI of chest
Laboratory studies, including a complete blood cell (CBC) count, erythrocyte sedimentation rate (ESR), and urinalysis, PSA, CEA
Activity alterations to avoid undue back irritation
Comfort measures, including medications
Spinal manipulative therapy within the first 6 weeks

Correct Answer: Laboratory studies, including a complete blood cell (CBC) count, erythrocyte sedimentation rate (ESR), and urinalysis, PSA, CEA

Explanation:

DISCUSSION: In the initial assessment of acute low back pain in adults, no diagnostic testing is indicated during the first 4 weeks in the absence of “red flags” for a serious underlying condition. The purpose of the initial assessment of acute low back pain in adults is to rule out serious underlying conditions presenting as low back pain. The Agency for Healthcare Policy and Research, in its 1994 clinical practice guideline, identified four serious conditions that may present with low back pain, including fracture, tumor, infection, and cauda equina syndrome. This patient has five “red flags” for a spinal tumor as a possible etiology of his low back pain, including age of older than 50 years, constitutional symptoms (recent weight loss), pain worse when supine, severe nighttime pain, and a history of cancer. Of these, his history of cancer is most significant, as greater than 90% of spinal tumors are metastatic. In order of frequency, breast, prostate, lung, and kidney make up approximately 80% of all secondary spread to the spine. In the presence of “red flags” for tumor or infection, it is recommended that the clinician obtain a CBC count, ESR, and a urinalysis. If these are within normal limits and suspicions still remain, consider consultation or seek further evidence with a bone scan, radiographs, or additional laboratory studies. Negative radiographs alone are insufficient to rule out disease. If radiographs are positive, the anatomy can be better defined with MRI.
REFERENCES: Agency for Health Care Policy and Research, Bigos SJ (ed): Acute Low Back Problems in Adults. Rockville, MD, US Department of Health and Human Services, AHCPR Publication 95-0642, Clinical Practice Guideline #14, 1994.
Gertzbein SD: Metastatic spine tumors, in Herkowitz HN, Dvorak J, Bell G, et al (eds): The Lumbar Spine, ed 3. Philadelphia, PA, Lippincott Williams & Wilkins, 2004, pp 792-802.

Question 24:

Which of the following factors is most likely to be associated with prolonged survival of total knee arthroplasty?

Options:

History of high tibial osteotomy
Diagnosis of traumatic arthritis
Diagnosis of rheumatoid arthritis
Diagnosis of osteoporosis
Diagnosis of osteonecrosis

Correct Answer: Diagnosis of rheumatoid arthritis

Explanation:

Question 25:

Options:

Dega iliac
Salter iliac
Pemberton iliac
Steele triple
Ganz or Bernese periacetabular

Correct Answer: Dega iliac

Question 26:

Options:

Sling immobilization and rest
Physical therapy for aggressive stretching
Intra-articular corticosteroid injection and stretching program
Manipulation of the shoulder under anesthesia
Arthroscopic subacromial decompression and capsular release

Correct Answer: Intra-articular corticosteroid injection and stretching program

Explanation:

Question 27:

Options:

Tear size
Pain scale score
Strength deficit
Patient expectations

Correct Answer: Patient expectations

Explanation:

Question 28:

Options:

Observation
Bracing
A “growing rod”
Distraction instrumentation and posterior arthrodesis
Hemivertebra excision and limited fusion

Correct Answer: Hemivertebra excision and limited fusion

Explanation:

DISCUSSION: Nakamura and associates have reported good results in patients with resection for hemivertebra-related congenital scoliosis who have a progression of their deformity. Because of the progression, observation is not appropriate for this patient’s deformity. Bracing has not been shown to alter the progression of congenital scoliosis. The “growing rod” technique is also not effective in preventing progression related to hemivertebra. Distraction instrumentation carries an increased risk of neurologic complications in children with congenital spine deformities. Progression after posterior arthrodesis alone can occur through the so-ca
l
ed “crankshaft phenomenon.”
REFERENCES: Nakamura H, Matsuda H, Konishi S, et al: Single-stage excision of hemivertebrae via the posterior approach alone for congenital spine deformity: Follow-up period longer than ten years.
Spine 2002;27:110-115.
Ruf M, Harms J: Posterior hemivertebra resection with transpedicular instrumentation: Early correction in children aged 1 to 6 years. Spine 2003;15:2132-2138.
Figure 95a Figure 95b Figure 95c Figure 95d

Question 29:

Triple arthrodesis in a reduced position

Options:

Open reduction of the vertical talus
Open reduction of the vertical talus will most likely prevent problems.
With observation only, the patient is likely to stand or walk and develop pressure problems. Talectomy will not produce the most usable foot.
Achilles tenotomy will not produce significant correction by itself. Triple arthrodesis will concentrate stress and lead to ulcers.

Correct Answer: Open reduction of the vertical talus

Explanation:

What percentage of the human genome represents the actual genes:

Question 30:

Options:

increased strength of the rotator cuff repair by creating thicker repair construct.
decreased size of the defect exposing the humeral head.
decreased stress in the rotator cuff at the site of the side-to-side repair.
decreased stress in the rotator cuff at the free margin and greater tuberosity interface.
decreased stress in the rotator cuff crescent cable.

Correct Answer: decreased stress in the rotator cuff at the free margin and greater tuberosity interface.

Explanation:

Question 31:

-Images from an MRI scan of this patient’s left hip are shown in Figure 30c through 30e. What is the most likely cause of his acute pain?

Options:

Significant cartilage loss on the acetabulum
Labral tear
Femoral neck stress fracture
Tendonopathy of the rectus femoris

Correct Answer: Labral tear

Explanation:

DISCUSSION FOR QUESTIONS 30 THROUGH 32
This patient has cam-type femoroacetabular impingement. Decreased internal rotation and a positive impingement test (forced flexion, adduction, and internal rotation) are classic findings. The lack of pain with resisted hip flexion makes hip flexor strain unlikely, and the lack of tenderness at the greater trochanter renders trochanteric bursitis unlikely. Although athletic pubalgia can be a source of longstanding groin pain, he lacks the pain with a resisted sit-up and tenderness along the pubic ramus that is frequently noted in patients with pubalgia. His radiographs reveal a focal femoral neck prominence consistent with cam impingement, although pistol grip deformities and flattening of the lateral femoral head are often present as well. His MRI scan shows a labral tear, which is common in cam impingement.Surgical treatment for cam impingement can be effective for symptomatic patients. Even among highlevel athletes, open surgical dislocation of the hip has been shown to have good results. Most patients with cam impingement can be treated with arthroscopic osteoplasty and achieve results comparable to those realized with open surgical dislocation. The literature describes success in terms of athletes returning to sports (even professional athletes) to be approximately 90% after arthroscopic treatment.Byrd and Jones described 5 patients who developed transient neurapraxias that resolved uneventfully.The patients in his series who had concomitant microfracture had a 92% return to sports within the follow-up period. Cam impingement has long been thought to be associated with a history of a slipped capital femoral epiphysis. The capitis in these patients is displaced posteriorly, resulting in a prominent anterior femoral neck and decreased hip internal rotation. Pincer impingement is associated with a deep acetabulum, such as protrusion acetabula and acetabular retroversion. A patient who underwent a periacetabular osteotomy can develop a more retroverted acetabulum as well.

Question 32:

Options:

aspiration of the femoral metaphysis.
IV antibiotics.
a biopsy.
immobilization in a well-padded splint for 2 to 3 weeks.
immobilization in a spica cast for 6 weeks.

Correct Answer: immobilization in a well-padded splint for 2 to 3 weeks.

Explanation:

Question 33:

Options:

parental abuse.
abnormal osteoclast function.
defective N-Ac-Gal-6 sulfate sulfatase enzyme.
a quantitative defect of type I collagen synthesis.
vitamin D deficiency.

Correct Answer: a quantitative defect of type I collagen synthesis.

Explanation:

Question 34:

Options:

UCBL orthoses.
triple arthrodesis with Achilles tendon lengthening.
medial calcaneal osteotomy with posterior tibial tendon reconstruction and flexor digitorum longus tendon transfer.
medial calcaneal osteotomy with posterior tibial tendon reconstruction, flexor digitorum longus tendon transfer, and lateral column lengthening.
gastrocnemius lengthening and serial casting.

Correct Answer: triple arthrodesis with Achilles tendon lengthening.

Explanation:

DISCUSSION: The patient has a pronounced deformity with pain and degenerative arthritis; therefore, triple arthrodesis is the treatment of choice. Gastrocnemius or Achilles tendon lengthening may be a necessary adjunct to the triple arthrodesis, but alone is inadequate to allow for correction. Because the ankle-foot orthosis has failed to provide relief, a UCBL is not likely to help. Osteotomy procedures are designed for lesser deformities and well-preserved joints.
REFERENCES: Nunley JA, Pfeffer GB, Sanders RW, et al (eds): Advanced Reconstruction: Foot and Ankle. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2004,
pp 115-120.
Walling AK: Symposium: Adult acquired flatfoot. Clin Orthop 1999;365:2-99.

Question 35:

Figure 37 shows the radiograph of a 21-year-old collegiate basketball player who has had mild midfoot aching for the past 4 months. What is the best course of action?

Options:

Functional bracing
Cast immobilization with weight bearing permitted
Cast immobilization with no weight bearing
Open reduction and internal fixation
Midfoot arthrodesis

Correct Answer: Open reduction and internal fixation

Explanation:

Question 36:

What spinal nerves in the cauda equina are primarily responsible for innervation of the bladder?

Options:

L1, L2, and L3
L4 and L5
L5 and S1
S2, S3, and S4
Filum terminale

Correct Answer: S2, S3, and S4

Explanation:

Question 37:

Options:

open reduction and internal fixation with a plate and screws.
open treatment with calcaneal bone graft.
percutaneous screw fixation with a 4.5-mm screw.
weight-bearing cast for 8 weeks.
spanning external fixation.

Correct Answer: percutaneous screw fixation with a 4.5-mm screw.

Explanation:

Question 38:

Which of the following patients has the highest risk of developing recurrent instability after an arthroscopic Bankart procedure for anterior shoulder instability? Review Topic

Options:

year old female, recreational soccer player with ligamentous laxity and an x-ray showing a Hill-Sachs lesion and loss of glenoid contour
year old male, who plays hockey recreationally with no laxity and an x-ray showing a loss of glenoid contour
year old female, competitive tennis player with no laxity and x-ray findings of a Hill-Sachs lesion and loss of glenoid contour
year old male, recreational basketball player with ligamentous laxity and x-ray findings of a Hill-Sachs lesion
year old male, competitive football player with no laxity and no abnormal x-ray findings.

Correct Answer: year old female, recreational soccer player with ligamentous laxity and an x-ray showing a Hill-Sachs lesion and loss of glenoid contour

Explanation:

Question 39:

What is the next most appropriate step in the orthopaedic management of this patient?

Options:

Axillary view
CT of the shoulder
Closed reduction
Sling and close follow-up
Functional brace

Correct Answer: Closed reduction

Explanation:

The next step in the management of this injury is completion of the shoulder trauma series. An axillary radiograph, which can be quickly performed in the emergency department, must be obtained to accurately assess the humeral head relationship to the glenoid. If difficulty is encountered, a “Velpeau” axillary may be substituted. If that fails to elucidate the status of the glenohumeral joint, a CT scan should be obtained.
OrthoCash 2020
Which of the following findings best describes the acetabular fracture shown in Figure 38?
Posterior column with articular impaction and a free fragment
Anterior column with articular impaction
Posterior wall with an intra-articular fragment
Posterior wall with articular impaction and a free intra-articular fragment
Posterior wall with articular impaction
Corrent answer: 4
The CT scan shows a posterior wall fracture with impaction of the articular surface and a free fragment within the joint. Proper treatment of this injury requires not only reduction and fixation of the posterior wall fragment but also removal of the free fragment and elevation of the depressed articular segment.
OrthoCash 2020
A 28-year-old female firefighter fell from the top of a three-story building in the line of duty. She sustained a displaced pelvic fracture with more than 5 mm displacement. Compared to normal healthy controls, these patients have a higher incidence of
normal sexual function and normal vaginal childbirth.
sexual dysfunction (dyspareunia) and normal vaginal childbirth.
normal sexual function and caesarean section childbirth.
sexual dysfunction (dyspareunia) and caesarean section childbirth.
normal sexual function and caesarean section childbirth until hardware removal.
Pelvic trauma in women has been shown to increase the risk of sexual dysfunction and dyspareunia. Additionally, caesarean section childbirth is
almost universal following pelvic trauma regardless of whether anterior pelvic hardware is present or not.
OrthoCash 2020
A 30-year-old man falls off a 7-foot ladder and sustains the injury seen in the radiograph and the CT scan shown in Figures 39a and 39b. Medical history is negative. Management of this injury should include which of the following?
Closed treatment and casting
Open reduction and internal fixation
Primary subtalar arthrodesis
Percutaneous fixation
External fixation
A Sanders type 2 intra-articular calcaneus fracture in a young healthy nonsmoker is best treated with open reduction and internal fixation. Whereas nonsurgical management is an option, Buckley and associates have shown that these fractures have a better outcome with surgical care. Percutaneous fixation is reserved for tongue-type fractures and subtalar arthrodesis is used in some type 4 fractures. External fixation has not been shown to be advantageous in closed fractures.
OrthoCash 2020
A 24-year-old woman fell from a horse and landed on her outstretched right arm. Radiographs reveal an elbow dislocation with a type II coronoid fracture and a nonreconstructable comminuted radial head fracture. What is the most appropriate management?
Radial head resection, open reduction and internal fixation of the coronoid, and medial collateral ligament repair
Radial head resection and lateral collateral ligament repair
Radial head arthroplasty alone
Radial head arthroplasty and lateral collateral ligament repair
Radial head arthroplasty, open reduction and internal fixation of the coronoid, and lateral collateral ligament repair
The combination of an elbow dislocation and a fracture of the radial head and coronoid is known as a terrible triad injury. To restore elbow stability, each injury must be addressed. The nonreconstructable radial head fracture requires implant arthroplasty. Open reduction and internal fixation of the coronoid is also necessary as is repair of the lateral collateral ligament complex which is usually avulsed from the lateral epicondyle region.
OrthoCash 2020
A 30-year-old man is brought to the emergency department after a motor vehicle accident. He has a closed midshaft femoral fracture and an intra-abdominal injury. He is currently in the operating room and the exploration of his abdomen has been completed. His initial blood pressure was 70/30 mm Hg and is now 90/50 mm Hg after 4 liters of fluid and 2 units of blood. His initial serum lactate was 3.0 mmol/L (normal < 2.5), 1 hour postinjury it was 3.5 mmol/L, and it is now 5 mmol/L. His core temperature is 93 degrees F (34 degrees C).
What is the most appropriate management for the femoral shaft fracture at this point?
Reamed intramedullary nailing
Traction
External fixation
Open plating
Mast suit
The patient has several indications that he is not ready for definitive fixation of the femoral shaft fracture at this point. He is cold with a core temperature of 93 degrees F, and hypothermia of less than 95 degrees F (35 degrees C) has been shown to be associated with an increased mortality rate in trauma patients. The patient has also not been resuscitated based on his increasing lactate levels and although controversial, it has been shown that temporary external fixation leads to a lower incidence of multiple organ failure and acute respiratory distress syndrome.
OrthoCash 2020
A 45-year-old male karate instructor sustained the injury shown in Figures 40a through 40c while practicing karate. The decision to proceed with surgery depends on which of the following factors?
MRI scan
Physical examination
Workers’ compensation status
Surgeon availability
Patient age
The most important criteria in determining the need for surgery following a nondisplaced or minimally displaced tibial plateau fracture is knee stability to varus/valgus stress. Soft-tissue injury noted on MRI may be addressed at a later time following fracture healing. This fracture pattern is amenable to nonsurgical management. Decisions regarding surgical intervention may be made up to 2 weeks after injury.
OrthoCash 2020
A 32-year-old man has a Glasgow Coma Scale score of 8 and an open pelvic fracture. The patient’s family reports that he is a Jehovah’s Witness. Initial hemodynamic instability has resolved. In the operating room during a washout, the patient’s blood pressure becomes unstable. What is the most appropriate action?
Consult the ethics committee before giving blood.
Use cell saver blood.
Ask the patient’s family for consent to give blood.
Use plasma expanders.
Give the patient blood.
Certain medical procedures involving blood are specifically prohibited in the belief system of a Jehovah’s Witness whereas others are not doctrinally prohibited. For procedures where there is no specific doctrinal prohibition, a Jehovah’s Witness should obtain the details from medical personnel and make his or her own decision. Transfusions of allogeneic whole blood or its constituents or preoperative donated autologous blood are prohibited. Other procedures, while not doctrinally prohibited, are not promoted such as hemodilution, intraoperative cell salvage, use of a heart-lung machine, dialysis, epidural blood patch, plasmapheresis, white blood cell scans (labeling or tagging of removed blood returned to the patient), platelet gel, erythropoietin, or blood substitutes. The patient should not be given blood. Plasma expanders should be used first to restore hemodynamic stability. Cell saver blood from an open wound is not recommended nor would there likely be enough from an open pelvic fracture to salvage. The patient’s family may be expressing their own beliefs rather than the patient’s beliefs and it would be better to ask the patient when he or she is more alert to determine what procedures they would allow. A consult with the ethics committee will unnecessarily delay an intervention that should restore hemodynamic stability.
OrthoCash 2020
Figure 50 shows the radiograph of a 26-year-old man who sustained an isolated open injury to his foot. Examination reveals no gross contamination in the wound. There is a palpable dorsalis pedis pulse and sensation is present on the dorsal and plantar aspects of the foot. Initial treatment should consist of wound debridement, antibiotics, and
talectomy.
reimplantation of the talus.
reimplantation of the talus with acute triple arthrodesis.
Syme amputation.
transtibial amputation.
The radiograph shows a complete extrusion of the talus. Reimplantation of the talus after wound debridement has been reported to be safe and successful, and provides for flexibility with any future reconstructive procedures.
OrthoCash 2020
Which of the following long bone fracture patterns occurs after a pure bending force is exerted to the bone?
Spiral
Oblique
Transverse
Segmental
Comminuted
A pure bending force produces a transverse fracture pattern. Spiral fractures are mainly rotational, oblique are uneven bending, segmental are four-point bending, and comminuted are either a high-speed torsion or crush mechanism.
OrthoCash 2020
A 38-year-old woman fell from a ladder onto her right hip. The radiographs and CT scan are shown in Figures 52a through 52d. What is the best surgical approach for this fracture?
Kocher-Langenbeck
Iliofemoral
Ilioinguinal
Extended iliofemoral
Triradiate approach
The fracture is an associated both column fracture. The best approach for this fracture is the ilioinguinal. The Kocher-Langenbeck is best for posterior injuries to the acetabulum and some transverse fractures. The iliofemoral alone is limited to high anterior column injuries. The extended iliofemoral and triradiate
approaches although useful for this fracture, have a higher rate of complications.
OrthoCash 2020
An otherwise healthy 26-year-old woman is involved in a high speed motor vehicle accident and sustains the injury shown in Figure 54 to her dominant right arm. Appropriate treatment of this injury complex includes
plating of the radial shaft fracture then open repair of the triangular fibrocartilage complex.
open reduction and internal fixation of the radius and ulna.
plating of the radius then closed reduction and evaluation of the distal radioulnar joint (DRUJ).
closed reduction of the radius and DRUJ.
plating of the radius then pinning of the DRUJ in pronation.
This Galeazzi fracture is an injury that requires surgical treatment in an adult. The algorithm includes anatomic reduction of the radial shaft and closed reduction of the DRUJ with assessment of stability. If the DRUJ remains unstable, supination of the wrist may reduce the DRUJ. If not, either open or closed reduction with pinning is undertaken. The closer the radius fracture is to the DRUJ, the more likely it is to be unstable.
OrthoCash 2020
A 40-year-old laborer sustains the injury shown in the radiograph and CT scan in Figures 56a and 56b. What is the most common complication associated with surgical intervention?
Chronic osteomyelitis
Planovalgus hindfoot
Plantar nerve entrapment
Wound dehiscence
Painful hardware
The patient has a severe Sanders type 4 calcaneus fracture. By far the most common complication associated with surgical treatment of calcaneus fractures is wound dehiscence.
OrthoCash 2020
Patients in compensated shock (normal vital signs) are thought to be at risk for which of the following?
A primed immune system with an increased risk of a systemic inflammatory response
Nothing since they are no longer in uncompensated shock and their vital signs have normalized
Higher nonunion rates after fracture fixation
Higher infection rates after definitive fracture fixation
Higher complication rates after temporizing external fixation of long bone fractures
Patients who are in compensated shock have normal vital signs but still have hypoperfusion of organ beds such as the splanchnic circulation due to preferential perfusion of the heart and brain. The response to this continued hypoperfusion may be the development of a systemic inflammatory response that may lead to multiple organ failure. The patients are thought to be at risk for a “primed” immune system due to the ongoing stimulation of the immune system and may have an exaggerated response to a second stimulus such as surgery or infection. Other markers of resuscitation should be used besides vital signs to determine when resuscitation has been completed. The use of temporizing fixation has been shown to lower systemic complication rates, and the infection and union rate after staged fixation is not altered.
OrthoCash 2020
A 14-year-old boy sustains a right leg injury after being thrown from his motorcycle while racing. He reports diffuse right leg pain starting at his knee and proceeding distally to include his foot. After the injury the patient’s mother reports the tibia moving posteriorly then anteriorly while she was supporting the leg. In the emergency department 4 hours after injury, examination reveals a large knee effusion, firm compartments of the leg, a palpable posterior tibialis pulse with a warm, pink foot, and capillary refill of 2 seconds at the toes. His blood pressure is 100/50 mm Hg. Motor examination is
intact, but there is decreased sensation in the dorsal first interspace and plantar aspect of the foot. Compartment pressure measurement reveals all four compartments with pressures of 33, 36, 33, and 38 mm Hg respectively. Radiographs are shown in Figure 59a and 59b. The remainder of the skeletal examination is normal. What is the optimal management for this injury?
Emergent four compartment fasciotomies
Emergent four compartment fasciotomies and open reduction and internal fixation of the fracture
Elevation of the limb overnight and four compartment fasciotomies in the morning
Elevation of the limb overnight and a recheck of compartment pressures in the morning
Emergent MRI of the knee and leg
Corrent answer: 2
The patient has a compartment syndrome based on the firm compartments of the leg and the elevated compartment pressures measured at the diastolic pressure reading. Muscle ischemia occurs quickly when compartment pressures are elevated, and within 6 hours irreversible damage can occur. Emergent fasciotomies permit decompression of all four compartments and reestablishment of vascular supply to the muscles. Stabilization of the fracture prevents further soft-tissue injury.
OrthoCash 2020
Resuscitation of a trauma patient who has been in hypovolemic shock is complete when which of the following has occurred?
The mean arterial blood pressure is above 90 mm Hg.
The pulse pressure has normalized.
Urine output is greater than 0.5 to 1 mL/kg/h.
Oxygen delivery has been maximized.
Aerobic metabolism has been restored in all tissue beds.
Shock can be defined as inadequate tissue perfusion. Resuscitation or the resolution of shock is defined as when oxygen debt has been repaid, tissue acidosis is eliminated, and aerobic metabolism has been restored in all tissue beds. The end points for resuscitation are not clearly defined, but occult shock can still be present in the setting of normal vital signs and normal urine output due to selective perfusion of organ systems.
OrthoCash 2020
A 12-year-old girl falls in gymnastics and sustains comminuted midshaft radius and ulna fractures. Closed reduction and cast immobilization are attempted but fracture redisplacement with 20 degrees of angulation occurs. Surgical treatment includes closed reduction and intramedullary fixation of both bones. What is the most common long-term complication for this fracture?
Infection
Malunion
Loss of forearm rotation
Refracture
Delayed union/nonunion
Healing of forearm fractures in skeletally immature patients is the usual outcome. The use of intramedullary fixation has been reported to result in a lower frequency of refractures when compared to plate osteosynthesis due to the absence of diaphyseal holes after plate removal, which are considered stress risers. Regardless of implant technique, malunion and infection are infrequent. Loss of forearm pronation and supination is a common occurrence in surgically treated fractures due to the higher degree of soft-tissue injury, and periosteal stripping leads to fracture site instability and fracture comminution.
OrthoCash 2020
The teardrop shape marked with an asterisk in Figure 61 represents what anatomic structure?
Anterior superior iliac spine
Sciatic buttress
A column of bone running from the anterior inferior iliac spine (AIIS) to the posterior superior iliac spine (PSIS)
The most superior portion of the roof of the acetabulum
Iliopectineal line
The teardrop can be visualized on the obturator outlet view of the pelvis and represents a thick column of bone that runs from the AIIS to the PSIS. Half pins for eternal fixation frames or screws can be inserted into this column for fixation of fractures.
OrthoCash 2020
A patient was treated with a revision reamed intramedullary nail for a nonunion 6 months ago. A current radiograph is shown in Figure

Question 40:

During a posterior cruciate ligament (PCL)-retaining total knee arthroplasty, a critical principle to remember is to

Options:

accurately tension the PCL.
use bony resection to adjust the joint line.
maintain a small amount of residual deformity.
use intraoperative fluoroscopy to ensure femoral roll back.

Correct Answer: accurately tension the PCL.

Explanation:

Question 41:

Figure 59 shows properties of a material being tested for use as an implant. What is represented by the portion of the stress-strain curve from point A to point B?

Options:

Elastic limit
Nonproportional behavior
Plastic behavior
Elastic behavior
Fracture point

Correct Answer: Elastic behavior

Explanation:

Question 42:

Options:

Increased rate of union
Decreased rate of infection
Shorter operative time
Lower rates of hip pain
Lower rates of knee pain

Correct Answer: Increased rate of union

Explanation:

Question 43:

Options:

Presence of a third-party abrasive particle
Disproportionate use of the limbs by the patient
Defective femoral head
Method of fixation of the femoral component
Method of sterilization and shelf life of the polyethylene

Correct Answer: Method of sterilization and shelf life of the polyethylene

Explanation:

DISCUSSION: Over the past three decades, gamma irradiation and air has been the most common method of sterilizing polyethylene used in total joint arthroplasty. This method of sterilization results in breakage of the chemical bonds within the polymer. While this promotes cross-linking, it also leaves the polyethylene vulnerable to oxidation, especially if packaged in an air environment. Oxidation has been shown to decrease polyethylene’s molecular weight, ultimate tensile strength, elongation, and toughness which results in a stiffer, more brittle material that is less resistant to wear. Severity of oxidation and a decrease in mechanical properties have been shown to be related to the length of time that the component is exposed to air (the shelf life). Currier and associates studied the clinical performance of gamma irradiated in air polyethylene components that had been shelf aged. They demonstrated that for the first
5 years of shelf life, polyethylene oxidized rather slowly. However, polyethylene components with a shelf life of more than 5 years would be expected to have minimal mechanical toughness and would likely fail rapidly if implanted. Bohl and associates evaluated 135 patients who had undergone total knee arthroplasty. Survivorship at 5 years was 100% for components with a shelf life of less than 4 years, 89% for components with a shelf life of 4 to 8 years, and 79% for components with a shelf life of more than 8 years. Sychterz and associates reported no correlation between shelf life and true wear rates for components with a shelf life of less
than 3 years. In summary, both in vivo and in vitro data suggest that shelf life in excess of
3 to 5 years has a direct effect on wear of polyethylene.
REFERENCES: Currier BH, Currier JH, Collier JP, et al: Shelf life and in vivo duration: Impacts on performance of tibial bearings. Clin Orthop 1997;342:111-122.
Bohl JR, Bohl WR, Postak PD, et al: The Coventry Award: The effects of shelf life on clinical outcome for gamma sterilized polyethylene tibial components. Clin Orthop 1999;367:28-38.
Sychterz CJ, Young AM, Orishimo K, et al: The relationship between shelf life and in vivo wear for polyethylene acetabular liners. J Arthroplasty 2005;20:168-173.

Question 44:

Options:

Arthroscopic chondroplasty
Autologous chondrocyte implantation
Microfracture
Arthroscopic drilling
Abrasion arthroplasty

Correct Answer: Autologous chondrocyte implantation

Explanation:

Question 45:

Options:

MRI to assess for posterior tibialis tendon damage.
enhanced CT to assess for an osteochondral fracture.
tenography of the peroneal tendons to assess for tendon sheath tearing with subluxation.
a bone scan to assess for occult fracture.
arthroscopy of the ankle to assess for articular cartilage damage.

Correct Answer: MRI to assess for posterior tibialis tendon damage.

Explanation:

Question 46:

Which of the following methods most reliably detects mechanical loosening of the hip?

Options:

Serial planar radiographs
Joint aspiration
Aspiration and arthrogram
Technetium Tc 99m scan
CT scan

Correct Answer: Serial planar radiographs

Explanation:

Question 47:

Options:

Extensor pollicis brevis (EPB)
Extensor carpi radialis brevis (ECRB)
Extensor digitorum communis (EDC)
Extensor carpi ulnaris (ECU)
Extensor carpi radialis longus (ECRL)

Correct Answer: Extensor digitorum communis (EDC)

Explanation:

DISCUSSION: Extensor tendon injuries have been reported after volar plating of distal radius fractures. The CT scan shows prominent dorsal hardware a few millimeters ulnar to Lister’s tubercle. The second compartment, the ECRL and ECRB, is radial to Lister’s tubercle. The ECU runs along the distal ulna. The contents of the fourth dorsal compartment run just ulnar to Lister’s tubercle. The EDC tendon is likely irritated in this patient. The EPB runs along the radial border of the radius and is well away from prominent hardware.
REFERENCES: Benson EC, Decarvalho A, Mikola EA, et al: Two potential causes of EPL rupture after distal radius volar plate fixation. Clin Orthop Relat Res 2006;451:218-222.
Cooney WP, Linscheid RL, Dobyns JH (eds): The Wrist: Diagnosis and Operative Treatment. Philadelphia, PA, Mosby-Year Book, 1998.

Question 48:

-A 75-year-old woman fell at home and sustained the injury seen in Figures 249a through 249c. What is the most appropriate treatment option?

Options:

Stand pivot transfer only
Bed rest with bathroom privileges
Partial weight bearing on the right
Weight bearing only after surgical intervention
Bilateral weight bearing as tolerated

Correct Answer: Bilateral weight bearing as tolerated

Question 49:

Options:

Loose body
Discoid lateral meniscus
Transverse meniscal ligament
Displaced lateral meniscus tear
Displaced medial meniscus tear

Correct Answer: Discoid lateral meniscus

Explanation:

Question 50:

A purulent flexor tenosynovitis of the thumb may communicate with the small finger flexor through which of the following structures?

Options:

Hypothenar space
Thenar space
Midpalmar space
Distal forearm (Parona’s space)
Lumbrical canal

Correct Answer: Distal forearm (Parona’s space)

Explanation:

Question 51:

Options:

Posterior interosseous nerve entrapment
Extensor pollicis longus rupture
Extensor pollicis longus entrapment
Distal radius malunion
Intersection syndrome

Correct Answer: Posterior interosseous nerve entrapment

Explanation:

Question 52:

Options:

humeral head arthroplasty.
observation.
arthroscopic capsular release.
grafting of the humeral head defect.
electrical stimulation.

Correct Answer: observation.

Explanation:

DISCUSSION: This rare complication occurs after fracture-dislocation and has been seen after surgical stabilization in the adolescent. In most reported cases, prolonged observation has been shown to result in revascularization.
REFERENCES: Pateder DB, Park HB, Chronopoulos E, et al: Humeral head osteonecrosis after anterior shoulder stabilization in an adolescent: A case report. J Bone Joint Surg Am 2004;86:2290-2293.
Wang P Jr, Koval KJ, Lehman W, et al: Salter-Harris type III fracture-dislocation of the proximal humerus. J Pediatr Orthop B 1997;6:219-222.

Question 53:

Options:

aspiration and steroid injection.
rest.
acromioplasty.
arthroscopic repair and decompression.
rehabilitation.

Correct Answer: arthroscopic repair and decompression.

Explanation:

DISCUSSION: The MRI scans reveal a large posterior paralabral cyst associated with a posterior-superior labral tear. The cyst appears as a well-defined, smoothly marginated mass with low signal intensity on T
1
-weighted MRI scans and with high signal intensity on T
2
-weighted MRI scans. MRI also reveals changes in the supraspinatus and infraspinatus muscles secondary to denervation, including decreased muscle bulk and fatty infiltration. MRI has the added advantage, compared with other imaging modalities, of detecting intra-articular lesions, such as labral tears, which are frequently associated with ganglion cysts of the shoulder. In this case of a professional baseball player with a space-occupying lesion causing nerve compression with an associated labral tear, the treatment of choice is arthroscopic decompression of the cyst and repair of the tear. Acromioplasty would not address the primary pathology in this patient.
REFERENCES: Cummins CA, Messer TM, Nuber GW: Suprascapular nerve entrapment.
J Bone Joint Surg Am 2000;82:415-424.
Martin SD, Warren RF, Martin TL, et al: Suprascapular neuropathy: Results of non-operative treatment. J Bone Joint Surg Am 1997;79:1159-1165.

Question 54:

- The lateral fragment of bone (Segond fracture) associated with an injury of the anterior cruciate ligament is the result of an avulsion of the

Options:

Oblique popliteal ligament
Lateral capsule
Popliteal tendon
Fibular collateral ligament
Posterior oblique ligament

Correct Answer: Lateral capsule

Explanation:

Question 55:

A 72-year-old woman falls onto her left hip after tripping over a curb during her daily 3-mile walk. An injury radiograph is shown in Figure A. What is the best long term solution?

Options:

Cannulated screws
Valgus intertrochanteric osteotomy
Unipolar hemiarthroplasty
Bipolar hemiarthroplasty
Total hip arthroplasty

Correct Answer: Unipolar hemiarthroplasty

Explanation:

Question 56:

Duchenne’s muscular dystrophy is a genetic disorder that is transmitted by which of the following modes of inheritance?

Options:

X-linked
Autosomal-dominant
Autosomal-recessive
Chromosomal duplication
Chromosomal deletion

Correct Answer: X-linked

Explanation:

DISCUSSION: Patients with Duchenne’s muscular dystrophy show progressive muscular weakness because of the absence of dystrophin and have the clinical picture of progressive muscle weakness. The condition is an X-linked genetic disease.
REFERENCES: Fitzgerald RH, Kaufer H, Malkani AL: Orthopaedics. St Louis, MO, Mosby Year Book, 2002, pp 1573-1583.
Smith SA, Swaiman HF: Muscular dystrophies, in Swaiman KF, Ashwall S (eds): Pediatric Neurology Principles and Practice, ed 3. St Louis, MO, Mosby, 1999, pp 1235-1237.

Question 57:

Options:

Localized pigmented villonodular synovitis (PVNS)
Biphasic synovial sarcoma
Nodular fasciitis
Synovial hemangioma DISCUSSION.. The incidental finding in the posterior intercondylar notch of the knee in this patient represents a benign synovial hemangioma. No intralesional calcifications are shown either on the plain radiographs or CT scan. The MRI scans reveal a hypervascular lesion with multiple filling defects, with hyperintensity on T2-weighted images and low to intermediate signal intensity on T1-weighted images. Histologically, vascular lakes within fine capillaries with a synovium on the surface of the lesion are characteristic of this condition. Many patients with synovial hemangioma present with pain, swelling, stiffness, or mechanical symptoms. As with PVNS, the disease can be localized or diffuse in nature. Surgical excision, either open or arthroscopic, is the recommended treatment. PVNS is the most common intra-articular tumor, but hypointensity in either the diffuse or localized type is characteristic on MRI scan in both T1- and T2-weighted images. Synovial sarcoma, although often found close to a joint, is not characteristically found within a joint. Nodular fasciitis is not found in intra-articular locations.

Correct Answer: Synovial hemangioma DISCUSSION.. The incidental finding in the posterior intercondylar notch of the knee in this patient represents a benign synovial hemangioma. No intralesional calcifications are shown either on the plain radiographs or CT scan. The MRI scans reveal a hypervascular lesion with multiple filling defects, with hyperintensity on T2-weighted images and low to intermediate signal intensity on T1-weighted images. Histologically, vascular lakes within fine capillaries with a synovium on the surface of the lesion are characteristic of this condition. Many patients with synovial hemangioma present with pain, swelling, stiffness, or mechanical symptoms. As with PVNS, the disease can be localized or diffuse in nature. Surgical excision, either open or arthroscopic, is the recommended treatment. PVNS is the most common intra-articular tumor, but hypointensity in either the diffuse or localized type is characteristic on MRI scan in both T1- and T2-weighted images. Synovial sarcoma, although often found close to a joint, is not characteristically found within a joint. Nodular fasciitis is not found in intra-articular locations.

Explanation:

Question 58:

Options:

discharge at this time may result in loss of motion and the necessity of manipulation under anesthesia.
the insurance company has no right to make such demands on the surgeon or the patient.
if the patient is discharged and fails to regain full motion, she will most likely file a suit against the insurance company.
the patient will require a follow-up examination in 6 weeks to evaluate her progress.
the patient will be given an extra set of exercises to perform at home.

Correct Answer: discharge at this time may result in loss of motion and the necessity of manipulation under anesthesia.

Explanation:

Question 59:

What is the most common complication of halo vest immobilization in adults?

Options:

Neurologic deterioration
Pin loosening
Pressure sores under the vest
Psychosis
Dural puncture

Correct Answer: Pin loosening

Explanation:

Question 60:

Options:

Rotator cuff tear
inadequate strengthening exercises
Instability
Tuberosity nonunion
Prosthetic loosening

Correct Answer: Tuberosity nonunion

Explanation:

DISCUSSION: The radiographs show nonunion of both the greater and lesser tuberosities. Tuberosity pull-off and nonunion remain among the most common causes of failed humeral head arthroplasty for fracture. Strict attention to securing the tuberosities to each other and to the shaft, and autogenous bone grafting from the excised humeral head will decrease the incidence of pull-off and improve healing rates. Active-assisted range-of-motion and strengthening exercises should be delayed until tuberosity healing is noted radiographically, usually at 6 to 8 weeks postoperatively.
REFERENCES: Hartsock LA, Estes WJ, Murray CA, et al: Shoulder hemiarthroplasty for proximal humeral fractures. Orthop Clin North Am 1998;29:467-475.
Hughes M, Neer CS: Glenohumeral joint replacement and postoperative rehabilitation.
Phys Ther 1975;55:850-858.
Compito CA, Self EB, Bigliani LU: Arthroplasty and acute shoulder trauma. Clin Orthop 1994;307:27-36.

Question 61:

Options:

Open reduction and plate fixation
Open reduction and intramedullary rod fixation with casting
Cast immobilization with expected remodeling of the fracture and near-full motion
Cast immobilization, accepting malunion and some dysfunction because surgical treatment has a high rate of nonunion in OI DISCUSSION-Teenagers with displaced midshaft forearm fractures do not remodel fully if the angulation is beyond 10 degrees after reduction. Excellent outcomes have been shown with intramedullary rodding as well as plate fixation. In patients with bone fragility, plate fixation poses higher risks for fracture attributable to stress shielding. Load sharing with intramedullary rodding is preferred in surgical management of fractures whenever possible. This patient is 15 years old with unacceptable reduction, so remodeling of this fracture would not be expected with closed management. Patients with OI are not at higher risk for nonunion with surgery; there is no reason to withhold surgery for this patient.

Correct Answer: Open reduction and intramedullary rod fixation with casting

Question 62:

An 18-month-old child sustains a crush amputation of the tip of the index finger. Bone is exposed, but the nail is intact. Management should consist of

Options:

dressing changes and healing by secondary intention.
a split-thickness skin graft.
a full-thickness skin graft.
a thenar flap.
a V-Y flap.

Correct Answer: dressing changes and healing by secondary intention.

Explanation:

DISCUSSION: Children have a much greater capacity to heal soft-tissue injuries than adults. Most crush or avulsion fingertip amputations in children, particularly those younger than age 2 years, can be treated with serial dressing changes, even with bone exposed.
REFERENCES: Das SK, Brown HG: Management of lost finger tips in children.
Hand 1978;10:16-27.
Fassler PR: Fingertip injuries: Evaluation and treatment. J Am Acad Orthop Surg
1996;4:84-92.

Question 63:

A 34-year-old male presents with elbow pain after sustaining a ground level fall 2 weeks ago. An injury radiograph is shown in Figure

Options:

Which of the following provocative maneuvers will most likely be positive?
Lateral pivot shift test
Milking maneuver
Chair rise test
Posterior drawer test
Gravity-assisted varus stress test Corrent answer: 5 Figure A demonstrates a fracture of the anteromedial coronoid. Patients with this injury pattern will have feelings of instability with the gravity-assisted varus stress test. Varus posteromedial rotatory instability (VPMRI) of the elbow is caused by a varus and posteromedial rotation force, resulting in rupture of the lateral collateral ligament (LCL) from its humeral origin. The medial coronoid process is subsequently forced against the medial trochlea, which results in fracture of the anteromedial portion. The most sensitive test is the gravity-assisted varus stress test. The arm is abducted to 90° and the patient is asked to flex and extend the elbow. The test is positive for pain, grinding, or instability during range of motion, as the ulnohumeral joint is closed medially by the lack of the buttress from the anteromedial coronoid. Treatment involves surgically addressing the anteromedial facet of the coronoid and repairing the LCL. Steinmann performed a review of coronoid process fractures. He reports that with an anteromedial coronoid fracture, the anteroposterior (AP) radiograph of the elbow will demonstrate progressive narrowing of the joint space from lateral to medial. They conclude that an important determinant of stability is the involvement of the sublime tubercle (insertion point of the MCL). When the sublime tubercle is involved, medial elbow instability is likely. Doornberg et al. performed a retrospective review of coronoid fracture patterns. They found that large fractures of the coronoid were involved with anterior and posterior olecranon fracture/dislocations, small transverse fractures were involved with terrible triad injuries, and anteromedial facet fractures were associated with VPMRI. Doornberg et al. performed a retrospective review of patients with fracture of the anteromedial facet of the coronoid. They report that if the fracture is not specifically treated, patients ultimately developed arthrosis. They report that the coronoid fracture may be secured with a plate, screw, or sutures. They conclude that secure fixation of the coronoid usually restores good elbow function. Figure A is an AP radiograph of the elbow demonstrating a fracture of the anteromedial facet of the coronoid. Illustration A is a fluoroscopic stress view demonstrating ulnohumeral instability due to an associated LCL injury. Illustration B is an AP radiograph demonstrating plate and screw fixation of the coronoid and suture anchor repair of the LCL. Incorrect Answers:

Correct Answer: Chair rise test

Explanation:

positive finding and is seen in valgus posterolateral rotatory instability of the elbow.
OrthoCash 2020

Question 64:

A patient notes pain under the first metatarsophalangeal joint following a soccer injury. The MRI scans shown in Figures 27a and 27b reveal what pathologic finding?

Options:

Sesamoid fracture
Phalangeal fracture
Osteochondral lesion
Disruption of the plantar plate
Rupture of the flexor hallucis tendon

Correct Answer: Disruption of the plantar plate

Explanation:

Question 65:

Examination of a hand with compartment syndrome is most likely to reveal which of the following?

Options:

Clenched fist
Intrinsic minus posturing
Pain with passive stretch
Compression of the superficial arch
Pallor

Correct Answer: Intrinsic minus posturing

Explanation:

DISCUSSION: In a study of 19 patients with compartment syndrome of the hand, all had tense swollen hands with elevated compartment pressures. Most patients were neurologically compromised so pain with passive stretch may be difficult to illicit. Arterial inflow is present in the arch and thus pallor is not present. The typical posture of the hand is not clenched, rather it is an intrinsic minus posture of metacarpophalangeal joint extension and flexion of the proximal and distal interphalangeal joints.
REFERENCES: Oullette EA, Kelly R: Compartment syndromes of the hand. J Bone Joint Surg Am 1996;78:1515-1522.
Dellaero DT, Levin LS: Compartment syndrome of the hand: Etiology, diagnosis, and treatment. Am J Orthop 1996;25:404-408.

Question 66:

An 8-year-old girl sustained a displaced fracture at the base of the femoral neck in a motor vehicle accident. Management should consist of

Options:

closed reduction and spica cast immobilization.
closed reduction and fixation of the femoral fracture with smooth pins across the physis.
open reduction and fixation with screws across the fracture and short of the growth plate, and a spica cast.
skeletal traction in a 90 - 90 position.
temporary traction until fixation with a specially ordered pediatric hip screw is possible.

Correct Answer: open reduction and fixation with screws across the fracture and short of the growth plate, and a spica cast.

Explanation:

DISCUSSION: Pediatric intracapsular hip fractures are challenging because of the high rates of complications, including osteonecrosis and varus malunion. These patients should be treated as emergencies. Principles of treatment include anatomic reduction with internal fixation. Screw fixation short of the physis is preferred and may need to be supplemented with spica cast immobilization. Fixation may be achieved with smooth pins across the physis when little metaphyseal bone is available. Fixation across the physis with threaded screws is acceptable only when the patient is close to skeletal maturity. Pediatric hip screws are appropriate if immediately available. Emergent open reduction, capsulotomy, or joint aspiration may decrease the rate of osteonecrosis.
REFERENCES: Cheng JC, Tang N: Decompression and stable internal fixation of femoral neck fractures in children can affect the outcome. J Pediatr Orthop 1999;19:338-343.
Azouz EM, Karamitsos C, Reed MH, et al: Types and complications of femoral neck fractures in children. Pediatr Radiol 1993;23:415-420.
Song
KS
, Kim YS, Sohn SW, et al: Arthrotomy and open reduction of the displaced fracture of the femoral neck in children. J Pediatr Orthop B 2001;10:205-210.
Morsy HA: Complications of fracture of the neck of the femur in children: A long-term follow-up study. Injury 2001;32:45-51.

Question 67:

What structure has been described as having a risk of injury with retractor placement on the sacrum during combined acetabular-pelvic ring surgery using the Stoppa approach with a lateral window?

Options:

External iliac artery
Obturator nerve
Corona mortis
L5 nerve root
Ilioinguinal nerve

Correct Answer: External iliac artery

Explanation:

Question 68:

Which of the following ligaments is the primary static restraint against inferior translation of the arm when the shoulder is in 0 degrees of abduction?

Options:

Middle glenohumeral
Inferior glenohumeral
Coracoacromial
Coracoclavicular
Coracohumeral

Correct Answer: Coracohumeral

Explanation:

Question 69:

A 28-year-old male sustains a fall on icy ground and fractures his ankle. An intraoperative fluoroscopy image is shown in Figure A. This fixation suggests that the mechanism of injury was one of

Options:

Pronation-abduction
Supination-adduction
Pronation-external rotation
Supination-external rotation
Dorsiflexion-axial loading

Correct Answer: Pronation-abduction

Explanation:

The fixation of the medial malleolus in the figure consists of a contoured reconstruction plate placed in buttress (antiglide) mode with screws running parallel to the joint surface and perpendicular to the fracture line. This fixation is indicated for vertical fractures of the medial malleolus from a supination-adduction (SA) shearing force.
A vertical fracture of the medial malleolus is characteristic of a Lauge-Hansen SA fracture. Bimalleolar SA fractures will also demonstrate a distal fibular avulsion. Another characteristic is impaction of anteromedial distal tibia by the talar dome. An anteromedial surgical approach allows visualization of this region, elevation of impaction, and bone grafting of the defect if necessary.
Dumigan et al. analyzed 4 different methods of treating vertical shear fractures with polyurethane models. They found that fixation with a 4 hole 1/3 tubular plate with 2 screws in the distal fragment was stiffer than fixation with the same plate with 1 screw in the distal fragment (3 in the proximal), fixation with two 3.5mm cortical screws with washers, and fixation with two 4mm cortical screws with washers. They recommend plating over screw-alone constructs.
McConnell et al. reported 8 cases of anteromedial marginal impaction in SA fractures. They note that 44 fractures were SA type. Following reduction and fixation, all 8 patients had excellent outcome and no arthritis. They recommend an anteromedial approach to the medial malleolus for visualization.
Figure A is a lateral radiograph showing fixation of both malleoli with reconstruction plates. Illustration A is an postoperative AP fluoroscopy image. Illustration B is an injury film demonstrating the same SA ankle fracture. Illustration C shows articular impaction at the medial shoulder of the ankle joint typical of SA injuries. Illustration D shows marginal impaction in SA fractures.
Incorrect Answers
(SBQ12TR.76) A 24-year-old male sustains the fracture dislocation shown in Figure
A. How is this fracture pattern best classified?
Moore I
Moore II
Schatzker III
Schatzker V
OTA type 41B3
Figure A shows a Moore Type II fracture. Moore type II fractures consist of fractures involving the entire tibial condyle, where the fracture line begins in the opposite compartment and extends across the tibial eminence.
A number of classification systems are used to describe tibial plateau fractures. The main classification systems that are widely used include Schatzker, AO/OTA, Hohl and Moore. The Moore classification describes high energy fracture-subluxation injuries of the knee. This is thought to have clinical implications as the type of fracture pattern can indicate an associated soft-tissue injury.
Moore retrospectively reviewed over a 1000 proximal tibia fractures to devise a classification systems based on the characteristic of five types of tibia plateau fracture patterns. He believed this system helped to better understand knee instability and concomitant soft-tissue injury. For example, Moore Type III fractures (rim avulsion) are associated with a high rate of neurovascular injury.
Figure A shows a fracture involving the entire tibial condyle. Illustration A shows a schematic diagram of the Moore classification (I - V). Illustration B shows a table that
describes the Moore classification (I - V).
Incorrect Answers:

Question 70:

Radial nerve palsy is most commonly associated with which of the following types of humeral fractures?

Options:

Proximal one third spiral
Proximal one third transverse
Distal one third spiral
Distal one third transverse
Middle one third

Correct Answer: Middle one third

Explanation:

Question 71:

Options:

Reduced radial artery pulse
Double break in the ipsilateral superior shoulder suspensory complex
Elevated hemidiaphragm
Musculocutaneous nerve deficit
Drooping of the left eyelid

Correct Answer: Reduced radial artery pulse

Explanation:

Question 72:

Options:

immediate repair of the ruptured patellar tendon insertion.
knee joint aspiration and injection of a local anesthetic to facilitate examination.
joint aspiration for culture, broad-spectrum antibiotics, and immobilization.
immobilization until comfortable, followed by protected range of motion and strengthening.
immediate fracture repair.

Correct Answer: immobilization until comfortable, followed by protected range of motion and strengthening.

Explanation:

Question 73:

Options:

Fourth cervical nerve root
Upper trunk of the brachial plexus
Middle trunk of the brachial plexus
Lateral cord of the brachial plexus
Axillary nerve

Correct Answer: Upper trunk of the brachial plexus

Explanation:

Question 74:

On an axial CT image, which of the following dimensions is considered to be indicative of a critical amount of lumbar spinal stenosis? Review Topic

Options:

AP canal diameter of less than 20 mm
AP canal diameter of less than 50 mm
Cross-sectional area of less than 100 mm2
Cross-sectional area of less than 50 mm2
Circumferential area of less than 25 mm

Correct Answer: Cross-sectional area of less than 100 mm2

Explanation:

Lumbar central stenosis is defined by an AP canal diameter of less than 10 mm or a cross-sectional area of less than 100 mm2 as measured on CT.

Question 75:

Which of the following is a contraindication to laminoplasty in a patient with cervical spondylotic myelopathy?

Options:

Space available for the cord of less than 8 mm
Ossification of the posterior longitudinal ligament
Fixed cervical kyphosis
Previous posterior surgery
Concomitant cervical radiculopathy

Correct Answer: Fixed cervical kyphosis

Explanation:

DISCUSSION: Laminoplasty or any posterior decompressive procedure is contraindicated in patients with cervical spondylotic myelopathy and cervical kyphosis. The residual kyphotic posture of the cervical spine results in persistent spinal cord compression. The other choices are not contraindications for laminoplasty. Concomitant cervical radiculopathy can be addressed at the time of laminoplasty with a keyhole foraminotomy.
REFERENCES: Emery SE: Cervical spondylotic myelopathy: Diagnosis and treatment. J Am Acad Orthop Surg 2001;9:376-388.
Spivak JM, Connolly PJ (eds): Orthopaedic Knowledge Update: Spine 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 235-247.

Question 76:

Options:

split-thickness skin graft.
thenar flap.
cross-finger flap.
lateral arm flap.
Moberg (volar advancement) flap.

Correct Answer: cross-finger flap.

Explanation:

DISCUSSION: The wound described indicates loss of soft tissue directly to the level of the tendon, precluding use of skin grafts if excursion of the tendon is desired. A cross-finger
flap is ideal for small wounds on the volar aspect of digits. A thenar flap is suitable for tip injuries. A lateral arm flap will not reach the fingers. A Moberg flap is limited to distal injuries of the thumb.
REFERENCES: Kappel DA, Burech JG: The cross-finger flap: An established reconstructive procedure. Hand Clin 1985;1:677-683.
Lister GD: Skin flaps, in Green DP, Hotchkiss RN (eds): Operative Hand Surgery, ed 3. New York, NY, Churchill Livingstone, 1993, p 1741.

Question 77:

Options:

Endoscopy
Gastrostomy
Colonoscopy
Laparotomy

Correct Answer: Colonoscopy

Explanation:

Question 78:

Options:

Electromyography and nerve conduction velocity studies
MRI
CT
Bone scan
Psychiatric evaluation

Correct Answer: MRI

Explanation:

Question 79:

Options:

radiation therapy alone.
en bloc resection and anterior fusion.
chemotherapy and bone marrow transplant.
posterior occipitocervical fusion and radiation therapy.
en bloc anterior resection followed by posterior occipitocervical fusion.

Correct Answer: posterior occipitocervical fusion and radiation therapy.

Explanation:

Question 80:

Options:

reconstruction with a metal augmented revision tibial implant.
reconstruction with a hinged prosthesis.
reconstruction with a structural allograft.
reconstruction with iliac crest bone graft.
filling the defect with cement.

Correct Answer: reconstruction with a metal augmented revision tibial implant.

Explanation:

DISCUSSION: Massive bone loss encountered in revision total knee arthroplasty remains a significant challenge. Recent reports have shown high success rates using structural allograft to reconstruct large structural bone defects. A hinged prosthesis is not required in this setting. In this patient, a large amount of posterior cortex has been lost, making the area too large to fill with cement or iliac crest bone graft. Because of her age, the treatment of choice is a revision tibial implant and metal augments. Structural allograft would be suitable in a younger patient.
REFERENCES: Mow CS, Wiedel JD: Structural allografting in revision total knee arthroplasty. J Arthroplasty 1996;11:235-241.
Engh GA, Herzwurm PJ, Parks NL: Treatment of major defects of bone with bulk allografts and stemmed components during total knee arthroplasty. J Bone Joint Surg Am 1997;79:1030-1039.
Clatworthy MG, Ballance J, Brick GW, et al: The use of structural allograft for uncontained defects in revision total knee arthroplasty: A minimum five-year review. J Bone Joint Surg Am 2001;83:404-411.

Question 81:

Options:

Growth arrest of the distal ulna
Growth arrest of the distal radius
Compartment syndrome
Radioulnar synostosis
Entrapment of the extensor pollicis longus (EPL) tendon

Correct Answer: Growth arrest of the distal ulna

Explanation:

DISCUSSION: The radiographs show a fracture of the distal radius and ulna physis. The most likely complication is growth arrest of the distal ulna. In contradistinction to physis fractures of the radius (growth arrest incidence of less than 5%), the incidence of growth arrest in the ulna is between 30% and 40%. Entrapment of the EPL tendon and cross union between the two bones is extremely rare.
REFERENCES: Vanheest A: Wrist deformities after fracture. Hand Clin 2006;22:113-120.
Cannata G, De Maio F, Mancini F, et al: Physeal fractures of the distal radius and ulna: Long-term prognosis. J Orthop Trauma 2003;17:172-179.
Ray TD, Tessler RH, Dell PC: Traumatic ulnar physeal arrest after distal forearm fractures in children. J Pediatr Orthop 1996;16:195-200.
Aminian A, Schoenecker PL: Premature closure of the distal radial physis after fracture of the distal radial metaphysis. J Pediatr Orthop 1995;15:495-498.

Question 82:

What is the most common location for localized pigmented villonodular synovitis (PVNS) to occur?

Options:

Ankle
Anterior knee
Posterior knee
Hip
Elbow

Correct Answer: Anterior knee

Explanation:

DISCUSSION: Localized PVNS is a form of the disease in which synovial proliferation is restricted to one area of a joint and causes the formation of a small mass-like lesion. The true incidence of this is unknown but is probably less common than the diffuse form of the disease. PVNS presents as a usually painful discrete mass. The anterior compartment of the knee is the most common location.
REFERENCES: Tyler WK, Vidal AF, Williams RJ, et al: Pigmented villonodular synovitis.
J Am Acad Orthop Surg 2006;14:376-385.
Kim SJ, Shin SJ, Choi NH, et al: Arthroscopic treatment for localized pigmented villonodular synovitis of the knee. Clin Orthop Relat Res 2000;379:224-230.

Question 83:

Options:

a lateral patellar restraining brace for practice and competition.
arthroscopic lateral retinacular release.
open medial retinacular plication.
medial tibial tubercle transfer.
Maquet tibial tubercle elevation.

Correct Answer: arthroscopic lateral retinacular release.

Explanation:

Question 84:

If a percutaneous iliosacral screw is placed too anteriorly, and the screw exits anterior to the sacral ala before re-entering the sacral body, what will be the most likely finding postoperatively?

Options:

Lack of ankle dorsiflexion
Lack of ankle plantarflexion
Lack of knee extension
Loss of bowel and/or bladder control
Lack of great toe extension

Correct Answer: Lack of ankle dorsiflexion

Explanation:

Question 85:

Options:

a snug figure-of-8 splint and observation for spontaneous reduction.
closed reduction under general anesthesia.
closed reduction under general anesthesia and percutaneous pinning.
open reduction and capsuloligamentous repair.
open reduction and wire stabilization of the joint.

Correct Answer: closed reduction under general anesthesia.

Explanation:

Question 86:

When performing a revision total knee arthroplasty, trial components are inserted and the knee is stable in extension and loose in flexion. Which step should be taken to create a stable construct?

Options:

Insert a constrained tibial insert
Insert a thicker tibial component
Insert a larger femoral component
Augment the distal portion of the femoral component

Correct Answer: Insert a larger femoral component

Explanation:

Question 87:

When posterior fusion with instrumentation to the sacrum is used to treat adult scoliosis, what instrumentation technique best increases the chance of a successful lumbosacral fusion?

Options:

Addition of sublaminar wires to the midlumbar spine
Cross-linking of the longitudinal rods
Use of multiple claw hook fixation in the upper thoracic spine
Use of large-diameter rods and pedicle screws
Fixation into both the ilium and the sacrum

Correct Answer: Fixation into both the ilium and the sacrum

Explanation:

Question 88:

Figure 1 is the MRI scan of a 35-year-old female soccer player who injured her knee during a game. Given the findings of the scan, physical examination is most likely to reveal

Options:

grade 2 pivot shift.
positive Thessaly test.
positive quadriceps active test.
positive dial test at 30°.

Correct Answer: grade 2 pivot shift.

Explanation:

Question 89:

Options:

Will not affect functional outcome
Will result in diminished thumb motion
Will result in diminished pinch strength
Will result in diminished grip strength
Will result in moderate activity-related pain back answer Question 61.03

Correct Answer: Will not affect functional outcome

Explanation:

Question 90:

What do the T2-weighted, fat-saturated MRI scans shown in Figures 1 through 4 reveal?

Options:

Posterior cruciate ligament (PCL) tear, isolated
PCL tear and medial meniscus tear
Anterior cruciate ligament (ACL) tear, isolated
ACL tear and medial meniscus tear

Correct Answer: ACL tear and medial meniscus tear

Explanation:

The MRI scans show that edema is noted on the femoral insertion of the ACL consistent with a high-grade or complete ACL tear. The ACL is not visualized on the sagittal view, although the torn meniscus can be seen in the notch. On the coronal image, there is an empty lateral wall sign indicating proximal
disruption of the ACL. The medial meniscus images show a disruption of normal meniscus morphology consistent with a bucket handle medial meniscus tear. Note the appearance on the sagittal MRI scan of what appears to be a second soft-tissue density in line with the PCL. This "double PCL" sign is highly
indicative of a displaced medial meniscus tear rather than a displaced lateral meniscus tear.

Question 91:

- Examination of a 45 year old construction worker who was crushed by falling dirt and buried to midchest level reveals hemodynamic instability; however, radiographs of the chest are normal, and results of a diagnostic peritoneal lavage are negative. Despite the administration of a fluid bolus and packed red blood cells, hemodynamic instability persists. A radiograph of the pelvis is shown in Figure 4. The next step in the management should be

Options:

Application of a pelvic external fixator
A pelvic sling
Angiography of the pelvis
Open reduction and internal fixation
Open packing of the pelvic hematoma

Correct Answer: Application of a pelvic external fixator

Explanation:

Question 92:

Options:

A genetic problem
Repetitive activities involving an open proximal femoral physis
Early closure of the proximal femoral physis
Hip dysplasia

Correct Answer: Repetitive activities involving an open proximal femoral physis

Explanation:

Question 93:

Options:

Closed head injury
Facial fractures
Splenic rupture
Pelvic ring injuries
Flail chest

Correct Answer: Closed head injury

Explanation:

Question 94:

- A 25-year-old patient who was wearing a seat belt in the back chair of a car involved in a head-on collision undergoes a laparotomy. During surgery, an injury to the sigmoid colon is identified and treated. Two days later the patient has back pain when sitting in a chair. What is the most likely diagnosis?

Options:

Sacral fracture
Burst fracture of L5
Cauda equina syndrome
Distraction-flexion injury at L3
Distraction-extension injury at L3

Correct Answer: Distraction-flexion injury at L3

Explanation:

Question 95:

Options:

Galvanic
Pitting
Fretting
Crevice

Correct Answer: Fretting

Explanation:

Question 96:

A 14-year-old boy is involved in a motor vehicle accident and sustains the injury shown in Figures 18a and 18b. What is the most likely diagnosis? Review Topic

Options:

Hawkins type I talar neck fracture
Hawkins type II talar neck fracture
Hawkins type III talar neck fracture
Hawkins type IV talar neck fracture
Talar body fracture

Correct Answer: Hawkins type II talar neck fracture

Explanation:

Question 97:

Options:

Lunotriquetral fusion
Distal radioulnar joint (DRUJ) tenodesis
Triangular fibrocartilage complex (TFCC) repair
Extensor carpi ulnaris (ECU) tendon sheath reconstruction Upon examination, this patient is exhibiting dislocation of the ECU tendon because of a disrupted sheath. He has failed nonsurgical measures, so surgery that would involve either direct repair or reconstruction of the tendon sheath is indicated. An option for reconstruction is to use a portion of the extensor retinaculum as a sheath substitute. Deepening of the ECU tendon groove at the distal ulna with direct repair of the sheath is another option, although a 2016 paper by Ghatan and associates did not find depth of the groove as a risk factor for subluxation. TFCC repair, lunotriquetral fusion, and DRUJ tenodesis are not appropriate because the examination clearly shows ECU tendon dislocation. TFCC and lunotriquetral ligament tears can occur along with ECU tendon dislocation, but no other examination findings suggest these conditions for this patient.

Correct Answer: Extensor carpi ulnaris (ECU) tendon sheath reconstruction Upon examination, this patient is exhibiting dislocation of the ECU tendon because of a disrupted sheath. He has failed nonsurgical measures, so surgery that would involve either direct repair or reconstruction of the tendon sheath is indicated. An option for reconstruction is to use a portion of the extensor retinaculum as a sheath substitute. Deepening of the ECU tendon groove at the distal ulna with direct repair of the sheath is another option, although a 2016 paper by Ghatan and associates did not find depth of the groove as a risk factor for subluxation. TFCC repair, lunotriquetral fusion, and DRUJ tenodesis are not appropriate because the examination clearly shows ECU tendon dislocation. TFCC and lunotriquetral ligament tears can occur along with ECU tendon dislocation, but no other examination findings suggest these conditions for this patient.

Explanation:

Question 98:

Options:

splint immobilization and early range-of-motion exercises.
radial head excision.
anatomic metallic radial head arthroplasty.
radial head open reduction and internal fixation.
anconeus interposition arthroplasty.

Correct Answer: anatomic metallic radial head arthroplasty.

Explanation:

DISCUSSION: Comminuted, displaced radial head fractures (Hotchkiss type 3) require anatomic metallic radial head arthroplasty to regain function. Radial head excision has led to catastrophic sequelae including chronic wrist pain, elbow instability, and proximal radius migration. Immobilization, internal fixation, or anconeus arthroplasty are not recommended at this time because of the potentially poorer outcomes.
REFERENCES: Hotchkiss RN: Displaced fractures of the radial head: Internal fixation or excision? J Am Acad Orthop Surg 1997;5:1-10.
Beredjiklian PK, Nalbantoglu U, Potter HG, et al: Prosthetic radial head components and proximal radial morphology: A mismatch. J Shoulder Elbow Surg 1999;8:471-475.

Question 99:

Options:

Hamstring autograft
Revision ACL reconstruction and posterior cruciate ligament (PCL) reconstruction
Revision ACL reconstruction and posteromedial corner reconstruction
Revision ACL reconstruction and posterolateral corner reconstruction

Correct Answer: Revision ACL reconstruction and posterolateral corner reconstruction

Explanation:

Question 100:

Figure 49 shows an acute axial MRI scan of a right knee. What is the most likely diagnosis? Review Topic

Options:

Patellar tendon rupture
Lateral dislocation of the patella
Quadriceps tendon rupture
Anterior cruciate ligament rupture
Posterior cruciate ligament rupture

Correct Answer: Lateral dislocation of the patella

Orthopedic Surgery Board Review MCQs: Arthroplasty, Trauma & Spine Part 255

Orthopedic Board Review MCQs: Foot & Ankle, Knee, & Deformity | Part 197

Key Takeaway

About This Board Review Set

How to Use the Interactive Quiz

Topics Covered in Part 197

Sample Questions from This Set

Why Active MCQ Practice Works

Chapter Index